DC Health · Have an illness or treatment explained to you in a language you can understand ....
Transcript of DC Health · Have an illness or treatment explained to you in a language you can understand ....
You can call us 24 hours a day, 7 days a week, or stop by our office Monday
through Friday from 8:00am – 5:30pm.
For directions on how to visit us, call (202) 821-1100.
Trusted Health Plan
1100 New Jersey Ave., SE
Ste. 840
Washington, DC 20003
Member Services (202) 821-1100
Toll Free (855) 326-4831
DC
Health
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Allia
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Important Phone Numbers For questions about Trusted call:
Member Services (202) 821-1100 OR (855) 326-4831 (toll free)
8:00am-5:30pm
Monday-Friday
If you need care after your doctor’s office closes or have a question you need to ask a nurse call:
Nurse Helpline (855) 872-1852 (toll free) 24 hours a day, 7 days a week
TTY/TDD After Hours dial 711 for TTY Assistance
24 hours a day, 7 days a week
If you need mental health care or have a mental health question call:
Your PCP’s Office (fill in your PCP’s information here)
DC Department of Behavioral Health Hotline
(888) 793-4357 24 hours a day, 7 days a week
If you need to see a doctor within 24 hours (“Urgent Care”) call:
Your PCP’s Office (fill in your PCP’s information here)
Nurse Helpline (855) 872-1852 (toll free)
24 hours a day, 7 days a week
If you need someone who speaks your language or if you are Hearing Impaired, call:
Member Services (202) 821-1100 OR (855) 326-4831 (toll free)
8:00am-5:30pm Monday-Friday
TTY/TDD 711 24 hours a day, 7 days a week
For dental questions: DentaQuest (800) 417-7140 8:00am-5:30pm Monday-Friday
FOR AN EMERGENCY, DIAL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM
Your Main doctor: ________________________________________ Phone: __________________________
Child’s Main doctor: ________________________________________ Phone: __________________________
Other Child’s Main doctor: ___________________________________ Phone: __________________________
Welcome to Trusted Health Plan Thank you for choosing Trusted Health Plan (Trusted) as your Medicaid Managed Care Organization
(MCO). Our commitment is to provide you with access to quality health care with excellent customer
service.
This Member Handbook contains important information about Trusted and how our plan works. We urge
you to review it carefully. As a Trusted member you will obtain great benefits and services. If Trusted
changes how it works or learns information about its medical providers that you need to know (such as
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which doctors are taking new patients and the doctors’ office hours), you will be informed about the
change 30 days before it occurs.
New members will receive an invitation in your New Member packet to our New Members Orientation as
well as a new member welcome call. The New Member Orientation is our way of providing you with a
personal way for you to learn how to best use our health care system and to ask any questions you may
have.
Quality Corner –
Did you know that you can get a copy of Trusted’s Quality Improvement Program summary? The summary
includes: QI program activities, goals and outcomes. Just call Member Services @ (202) 821-1100 or visit
our website at www.trustedhp.com (member resource section).
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How this Handbook Works Trusted is a managed care plan that is paid by the District of Columbia to help you get health care. In this
Handbook we tell you about how Trusted works, how to find doctors, how to call us, and what things we
pay for.
Telling you about these things can be hard to do – and hard for everyone to read. Words used in health care
and words used by your doctor can sometimes be hard to understand, Sometimes we have to tell you about
laws that you need to know about. These also can be hard to understand. To help you, we have underlined
some words that might have a different meaning from the one you know. We have explained these words in
the back of this book.
If you ever have any questions about things you read in this book or other questions about Trusted
you can call Trusted Member Services at (202) 821-1100 or visit www.Trustedhp.com we will do our
best to help you.
This Member Handbook gives you basic information about how Trusted works and its rules. Please call
Trusted Member Services if you have any questions 24 hours a day, seven days a week.
How this Member Handbook Can Help You
This Member Handbook tells you:
How to get health care
What Services we will pay for (we call this, what Services are “covered” by us)
What Services we can’t pay for
How to pick your Primary Care Provider (your PCP)
What to do if you get sick
What you should do if you have a Complaint (also called a “Grievance”) or want to
change (“Appeal”) a decision by Trusted
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Table of Contents
Important Phone Numbers ........................................................................................................................... 2 Welcome to Trusted Health Plan .................................................................................................................. 2 How this Handbook Works ........................................................................................................................... 4 Your Rights and Responsibilities ................................................................................................................... 7 Your Member ID Card ................................................................................................................................. 11 Your Primary Care Provider (PCP)............................................................................................................... 12 Picking your PCP ......................................................................................................................................... 12 How to change your PCP ............................................................................................................................ 13 Routine Care, Urgent Care and Emergency Care ....................................................................................... 13 When you are Out of Town: ....................................................................................................................... 14 Trusted Providers and Providers who are not part of Trusted ................................................................... 15 Making an Appointment ............................................................................................................................. 16 Making an Appointment with your PCP ..................................................................................................... 16 Changing or canceling an Appointment ..................................................................................................... 16 Getting care when your PCP’s office is closed ............................................................................................ 16 How long it takes to see your doctor ......................................................................................................... 17 Support Services ......................................................................................................................................... 19 Interpretation & Translation Services/Services for the hearing and visually impaired ............................. 19 Interpretation Services ............................................................................................................................... 19 Translation Services .................................................................................................................................... 19 Services for the Hearing and Visually Impaired .......................................................................................... 19 Transportation Services .................................................................................. Error! Bookmark not defined. Specialty Care and Referral ........................................................................................................................ 19 How to get specialty care ........................................................................................................................... 19 Self-Referral Services .................................................................................................................................. 20 You DO NOT need a Referral to: ................................................................................................................. 20 Mental Health Services ............................................................................................................................... 20 Services for alcohol or other drug problems .............................................................................................. 20 Birth control and other Family Planning Services ...................................................................................... 21 Pharmacy Services and prescription drugs ................................................................................................. 22 Disease Management ................................................................................................................................. 22 Services to Keep Adults from Getting Sick ................................................................................................. 22 Recommendations for Checkups (“Screenings”) ........................................................................................ 22 Preventive counseling................................................................................................................................. 23 Adult Immunizations .................................................................................................................................. 23 Pregnancy ................................................................................................................................................... 23 Prenatal and Post-Partum Care .................................................................................................................. 24 Once you have had your baby, call: ............................................................................................................ 24 Your Child’s Health ..................................................................................................................................... 24 Health Check Program for Children (EPSDT) .............................................................................................. 24 Immigrant Children ..................................................................................................................................... 24 Care for your children’s teeth..................................................................................................................... 25 Children with Special Health Care Needs ................................................................................................... 26 The IDEA program ....................................................................................................................................... 26 Trusted covers the services listed below if your child is in the IDEA program: .......................................... 27
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Immunizations (shots) for children and teens ............................................................................................ 28 Your Health Benefits ................................................................................................................................... 28 Health Services covered by Trusted ........................................................................................................... 28 Services We Do Not Pay For ....................................................................................................................... 33 Other Important Information ..................................................................................................................... 34 What to do if you move .............................................................................................................................. 34 What to do if you have a baby.................................................................................................................... 34 What to do if you adopt a child .................................................................................................................. 34 What to do if someone in your family dies ................................................................................................ 34 How to change your Managed Care Organization ..................................................................................... 34 What to do if you get a bill for a covered service ....................................................................................... 35 Paying for Non-Covered Services ............................................................................................................... 35 Advance directives ...................................................................................................................................... 35 What to do if you have other insurance ..................................................................................................... 36 What to do if you are eligible for both Medicaid and Medicare ................................................................ 36 Physician (doctor) incentive plan disclosure .............................................................................................. 36 Complaints/Grievances, Appeals and Fair Hearings ................................................................................... 36 Complaints/Grievances .............................................................................................................................. 36 Appeals and Fair Hearings .......................................................................................................................... 37 Appeals ....................................................................................................................................................... 37 Expedited (Emergency) Complaints/Grievances and Appeals process ...................................................... 38 Your rights during the Complaints/Grievances, Appeals and Fair Hearings process ................................. 38 The District’s Ombudsman Program .......................................................................................................... 38 Notice of Privacy Practices ......................................................................................................................... 40 Why Are You Giving This Notice to Me? ..................................................................................................... 40 What is Trusted Health Plan Required to do Under HIPAA? ...................................................................... 40 What is Protected Health Information (PHI) .............................................................................................. 40 How Can You Use or Share my PHI? ........................................................................................................... 40 What are my Rights Under Federal Law with Respect to my PHI? ............................................................. 42 May I Complain about Your Privacy practices? .......................................................................................... 43 How will I know if my rights change? ......................................................................................................... 43 Medicare Part D Notice to Members ............................................................. Error! Bookmark not defined. For Members with both Medicare and Medicaid .......................................... Error! Bookmark not defined. What Some Words Mean ........................................................................................................................... 45
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Your Rights and Responsibilities
You have a right to:
Be treated with respect and dignity.
Know that when you talk with your doctors and other providers its private.
Have an illness or treatment explained to you in a language you can understand.
Participate in decisions about your care.
Refuse treatment or care.
Be able to see your medical records and to request that they be fixed if they are wrong.
Choose an eligible PCP from within Trusted’s network and to change your PCP.
Make a Complaint (“Grievance”) about the care provided to you and receive an answer.
Request an Appeal or a Fair Hearing if you believe Trusted was wrong in denying, reducing or stopping a
service or item.
Obtain medical care without unnecessary delay
Receive information on advance directives and choose not to have or continue any life-sustaining treatment.
Receive a copy of Trusted Member Handbook.
Continue treatment you are currently receiving until you have a new treatment plan.
Receive interpretation and translation services free of charge if you need them.
Refuse oral interpretation services.
Get an explanation of prior authorization procedures.
Obtain summaries of customer satisfaction surveys
Receive Trusted’s “Dispense As Written” policy for prescription drugs.
Receive family planning services and supplies from the provider of your choice.
Be free from any form of restrain or seclusion used as coercion, discipline, convenience or retaliation, as
specified in other federal regulations on the use of restrains and seclusion.
Receive information about benefits available under the District plan, but not covered by Trusted.
To a candid discussion of appropriate or medically necessary treatment options for your conditions regardless
of cost and benefit coverage.
Have direct access to a women’s health specialist within the network for the covered care necessary to provide
women’s routine and preventive healthcare services. Also, female enrollees have a right to designate as their
PCP a participating provider or an advanced practicing registered nurse who specializes in obstetrics (OB)
and gynecology (GYN).
Ask for a chaperone to be present when you receive health care.
Receive information about Trusted Health Plan’s financial condition and any special ways we pay our doctors.
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Your Rights and Responsibilities –Continue
You have a right to:
Received information about Trusted Health Plan, our services, our providers and other health care workers,
our facilities, and your rights and responsibilities as a member.
Receive a second opinion from a qualified health care provider within the network, or arrange for the enrollee
to obtain one outside the network, at no cost to you.
Be informed about how and where to access any benefits available under the district of Columbia plan but not
covered under the contract, including any cost sharing, and how transportation is provided upon enrollment,
annually an at least 30 days prior to any change.
Not be held liable for the Trusted Health Plan’s debts in the event of the Trusted Health Plan’s insolvency.
Use any hospital or other setting for emergency care.
Be treated no differently by providers or by Trusted Health Plan for exercising your rights listed here.
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You are responsible for:
Treating those providing your care with respect and dignity.
Following the rules of the D.C. Medicaid Managed Care Program and Trusted Health Plan.
Following plans and instructions you receive from your doctors and other providers.
Going to Appointments you schedule or that Trusted schedules for you.
Telling your doctor at least 24 hours before the Appointment if you have to cancel.
Asking for more explanation if you do not understand your doctor’s instructions.
To make recommendations regarding Trusted Health Plan’s Member Rights and Responsibilities policy.
Going to the Emergency Room only if you have a medical emergency.
Telling Trusted and your PCP about medical and personal problems that may affect your health, to help them
to provide you care.
Reporting to Economic Security Administration (ESA) and Trusted if you or a family member have
other health insurance.
Trying to understand your health problems and participate in developing treatment goals to help Trusted and
PCP provide your care.
Helping your doctor get medical records from providers who have treated you in the past.
Telling Trusted if you were injured as the result of an accident or at work.
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The THP Compliance Program offers a confidential and anonymous telephone hotline available 24/7 to voice your
concerns about any situation that may conflict with Compliance Program principles. If you want to report concerns
or suspicions regarding:
Compliance with federal or district law
Compliance with THP policies
Suspected fraud, waste or abuse
Possible ethical or code of conduct violations
You may also send a message to our inbox:
You may also come speak to our Compliance Officer, George Aloth, directly.
Your report will remain confidential and your privacy will be respected! No individual who reports Compliance Plan
violations or suspected fraud and abuse is retaliated against by anyone who is employed by or contracts with THP.
Anyone who believes that he or she has been retaliated against may report this violation to the DHCF Office of
Program Integrity and/or the U.S. Office of Inspector General.
COMPLIANCE
REPORTING
855 – 228 – 1700
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Your Member ID Card After you sign up for Trusted and you have picked a primary care provider (PCP), we will send you a
Member ID Card in the mail. This card lets your doctors, hospitals, pharmacies and others know that you
are a Member of Trusted. Please make sure that the information on your Member Identification Card is
correct. If there are any problems, or if you have lost your card, call Member Services (202) 821-1100 or
(855) 326-4831 (toll free).
Your Member ID Card Looks Like This
Each Trusted Member has his or her own card. Your children will also have their own cards, you must keep
your children’s cards so they don’t get lost. It is against the law to let anyone else use your Member ID
Card or Medicaid card.
Please remember to carry your Member ID Card with you all the time. Always show your
card before receiving any medical care or getting medicine at a pharmacy.
Be sure to keep your Medicaid Card too.
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Your Primary Care Provider (PCP) When you join Trusted, one of our doctors will be your main doctor. This doctor is called your Primary
Care Provider or PCP. Your PCP will help you and your family get the health care you need.
It is important to call your PCP first when you need care. If you had a doctor before you signed up with
Trusted please call Member Services at (855) 326-4831. We can help you stay with that doctor if you want
to.
To find more information about Trusted doctors, go to our website or call Member Services at (202) 821-
1100. You will find information about the doctors’
Name, Address and telephone numbers
Professional qualifications
Specialty
Education including the medical school attended
Residency
Board Certification Status
Picking your PCP
1. Pick a PCP at the time you enroll in Trusted. This person will be your PCP while you are a
member of Trusted.
If your current PCP is a member of Trusted’ s network, you may stay with that doctor.
If you don’t have a PCP, you can choose from a list of doctors in our Provider Directory or at
www.Trustedhp.com
Call Member Services at (202) 821-1100 if you need help in picking a doctor.
If you do not pick a PCP within the first 10 days of being in our plan, we will choose a doctor for
you. If you do not like the PCP we pick for you, you may change your PCP. Call Member
Services at (202) 821-1100 to change your PCP.
Trusted will send you a Member ID Card. Your card will have your PCP’s name and phone
number on it.
2. Choose a PCP for each family member in our plan, including your children. Your PCP may be
one of these kinds of doctors:
Family and General Practice Doctor - usually can see the whole family
Internal Medicine Doctor - usually sees only adults and children 14 years and older
Pediatrician - sees children from newborn up to adult
Obstetrician/Gynecologist (OB/GYN) - specializes in women’s health and Maternity care
If you or your child has Special Health Care Needs, a specialist may be your PCP but you need
to call us as and let us know that you would like this. We will try to help you get a specialist to
be your PCP, but the specialist would have to agree to it.
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3. When you pick your PCP, please:
Pick a doctor who is close to your home or work.
Try to pick a doctor who can send you to the hospital you want. Not all doctors can send patients
to all hospitals. Our provider directory lists which hospitals a PCP can send you to. You can also
call Member Services for help.
Sometimes the PCP you choose won’t be able to take new patients. We will let you know if you
need to pick a different doctor.
How to change your PCP
You can change your PCP anytime. Just pick a new PCP from the Provider Directory. Call Member
Services at (202) 821-1100 once you have picked a new PCP. If you need help picking a new PCP,
Member Services can help you.
Routine Care, Urgent Care and Emergency Care There are three kinds of health care you may need: Routine Care, Urgent Care, or Emergency Care.
Routine Care is the regular care you get from your PCP. Routine Care is also care you get from other
doctors that your PCP sends you to. Routine Care can be Check-Ups, physicals, health Screenings, and care
for health problems like diabetes, hypertension, and asthma. If you need Routine Care, call your PCP’s
office and ask to make an Appointment.
Urgent Care is medical care you need within 24 hours, but not right away. Some Urgent Care issues are:
A sprain or a strain
Throwing Up
Lice, scabies or ringworm
An earache
A cough or cold
Refills for medicine
Diarrhea
A cut or scrape
A sore throat
Diaper rash
Mild Headache
If you need Urgent Care, call your PCP’s office. If your PCP’s office is closed, leave a message with the
person who answers the phone when the office is closed. Then call the Nurse Help Line at (855) 872-1852.
A nurse will help you decide if you need to go to the doctor right away. The nurse will tell you how to get
care. You do not have to go to the Emergency Room or use an ambulance for routine or Urgent Care.
Emergency Care is medical care you need right away for a serious, sudden (sometimes life-threatening)
injury or illness. Emergency Medical Conditions are:
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Miscarriage/pregnancy with vaginal bleeding
Bleeding that won’t stop
A broken bone
A bad burn
You are in labor
Drug overdose
Shock (you may sweat, feel thirsty or dizzy or have pale skin)
Seizures
Poisoning
Fainting/unconsciousness
Gun or knife wounds
Suddenly not able to see, move or speak
Care When You Are Out-of-Town
When you are Out of Town: When you need to see a doctor or get medicine when you are out-of-town, you should:
For Routine Care: You must call us and ask if we will pay for you to see a doctor or other provider when
you are out of town because doctors who are not in the District of Columbia are not a part of Trusted. If
Trusted does not say it is okay before you get the care, you will have to pay for the care yourself. If you
need medicine from a doctor while you are out-of-town, please call our Member Services Department or
Nurse Advice Line for help.
For Urgent Care: Call your PCP. If your PCP’s office is closed, call the Nurse Help Line (855) 872-1852.
A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get
care. You do not have to go to the Emergency Room or use an ambulance for routine or Urgent Care.
For Emergency Care: If you have an emergency, including a mental health or alcohol or other drug
emergency, go to the nearest Emergency Room (ER) to get care right away. If you go to the emergency
room, you should ask the ER staff to call your PCP. If you go to the emergency room, you should call
Member Services as soon as you can.
If your child does not live at home and needs to see a doctor, please call Member Services at (202)
821-1100.
WHAT TO DO IF YOU HAVE AN EMERGENCY:
1. Call 9-1-1 or go to your nearest emergency room.
2. Show the Emergency Room (ER) your Trusted Member I.D. Card.
3. As soon as you can, call your PCP.
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Trusted Providers and Providers who are not part of
Trusted Trusted will pay for the care you get when you go to one of our doctors or other health care providers. We
call these doctors and other health care providers our “network” providers. All these “In-Network” doctors
can be found in your Provider Directory. A doctor or provider who is not one of ours is called an “Out-of-
Network” Provider.
If you go to an “Out-of-Network” doctor, hospital or lab, you may have to pay for the care you get. You will
not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call
this “prior written authorization.”
Prior authorization (or prior approval) means approval for a health service that is not routinely covered by
Trusted. You must get this approval before you receive the service. To ask about getting a prior
authorization call the Utilization Management Department at (202) 821-1145.
You may go to a Family Planning provider who is out-of–network even if you do not have prior
authorization. See page 19 for more information on Family Planning Services.
You may go to an Emergency Room which is out-of–network even if you do not have prior authorization.
Remember: You need to go to a provider in Trusted’s network.
Utilization Management (UM)
If you have a question about an approval or denial of medical services or procedures, call the Utilization
Management Department at (202) 821-1145 or toll-free at (855) 326-4831, Monday – Friday 8:00 – 5:30.
TDD/TTY and language services are available.
Decisions about whether Trusted covers a service are based on well-known and agreed upon rules
on what is best for your health and what is covered by your Medicaid plan (your
benefits). Trusted does not give bonuses to doctors for saying no to (denying) your request.
Money is not used to reward doctors that deny or limit health services you may feel you want or
need.
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Making an Appointment
Making an Appointment with your PCP
1. Have your Member ID Card and a pencil and paper close by.
2. Call your PCP’s office. Look for your PCP’s phone number on the front of your Member ID Card.
You can also find it in your Provider Directory or online at www.Trustedhp.com
3. Tell the person who answers that you are a Trusted Member. Tell them you want to make an
Appointment with your PCP.
4. Tell the person why you need an Appointment. For example:
a. You or a family member is feeling sick
b. You hurt yourself or had an accident
c. You need a check- up or follow-up care
5. Write down the time and date of your Appointment.
6. Go to your Appointment on time, and bring your Member ID Card with you.
7. If you need help making an Appointment, please call Member Services at (202) 821-1100.
Changing or canceling an Appointment It is very important to go to your Appointment and to be on time.
If you need to change or cancel your Appointment, please call the doctor at least 24 hours before your
Appointment.
For some Appointments, you may have to call more than 24 hours before to cancel.
If you do not show up for your Appointment or if you are late, your doctor may decide you cannot be his or
her patient.
Getting care when your PCP’s office is closed
If you need to speak to your PCP when the office is closed, call your PCP’s office and leave a message with the
person who answers the phone when the office is closed. Be sure to give the person who answers your phone
number. Someone will call you back as soon as possible. You can also call the Nurse Help Line 24 hours a day at:
(855) 872-1852. If you think you have an emergency, call 911 or go to the Emergency Room.
If you are a new Member of Trusted, you should make
an Appointment for your first health Check-Up as soon as possible.
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How long it takes to see your doctor Your doctor’s office must give you an Appointment within a certain number of days after you call. The table
below shows how long it will take to get an Appointment. Please call (202) 821-1100 if you cannot get an
Appointment during these time periods.
Type of visit Your condition How long it takes to
see your doctor
Urgent Visit
You are hurt or sick and need care within 24 hours to avoid getting
worse, but you don’t need to see a doctor right away
Some examples of when you need urgent care are: a sprain or strain,
diarrhea, throwing up, a cut or scrape, an earache, a sore throat, a
cough or cold, diaper rash, refills for medicine, mild headache, lice,
scabies, or ringworm.
Within 24 hours
Routine Visit You have a minor illness or injury or you need a regular checkup, but
you don’t need an urgent Appointment. Within 30 days
Follow-up Visit You need to see your doctor after a treatment you just had to make
sure you are healing well.
Within 1-2 weeks
depending on the kind
of treatment
Adult Wellness
Visits
You are having your first Appointment with a new doctor
You are due for a regular adult checkup
You are due for a prostate exam, a pelvic exam, a PAP smear or a
breast exam
Within 30 days or
sooner if necessary
Non-urgent
Appointments with
specialists (by
Referral)
Your PCP referred you to see a specialist for a non-urgent condition Within 30 days
Child EPSDT
checkups -not urgent Your child is due for an EPSDT checkup
Initial checkup:
within 60 days
Additional checkups:
within 30 days of due
dates for children
under age two; within
60 days of due dates
for children age two
and older
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Immigrant Children
well-child checkups
– not urgent
Your child is due for a well-child checkup
Initial checkup:
within 60 days
Additional checkups:
within 30 days of due
dates for children
under age two; within
60 days of due dates
for children age two
and older
IDEA (Early
Intervention)
assessments
Tests (“assessments”) for children up to age 3 at risk of developmental
delay or disability Within 30 days
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Support Services
Interpretation & Translation Services/Services for the hearing and visually impaired
Interpretation Services Trusted will provide oral interpretation Services if you need them, including at the hospital
Please call Member Services at (202) 821-1100 to get Interpretation Services. Please call Trusted before
your doctor’s Appointment if you need interpretation Services.
Interpreter Services are usually provided over the telephone. If you need an interpreter to be with you at
your doctor’s Appointment, you must let us know 2 days or 48 hours before the Appointment.
DC uses 6 languages, Spanish, French, Amharic, Chinese, Korean and Vietnamese.
Translation Services If you get information from Trusted and need it translated into another language, please call the Member
Services Department at (202) 821-1100.
Services for the Hearing and Visually Impaired If you have trouble hearing, call Member Services at (202) 821- 1152
If you have trouble seeing, call Member Services at (202) 821-1100 or (855) 326-4831 (toll free). We can
give you information on an audio tape, in Braille or in large print.
Specialty Care and Referral
How to get specialty care Specialty care is when care is given by a specialist doctor who has extra training and cares for a specific
condition or part of the body. For example, a Cardiologist cares for the heart and a Podiatrist cares for the
feet.
Your PCP will help you know when you need to see a specialist and give you a referral. A referral is a
written note given to you by your PCP to see a different doctor. You must get a referral to see a doctor
other than your PCP except for well-women visits, family planning, and some mental health services.
If you want to see a specialist, but Trusted said it wouldn’t pay for the visit, you can:
Interpretation and translation Services and Services for the hearing and
visually impaired are FREE.
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Make an Appointment with another doctor in the Trusted network and get a second opinion
Appeal our decision (see page 36 on Appeals)
Ask for a Fair Hearing (see page 36 on Fair Hearings)
Self-Referral Services
There are certain services you can get without getting prior permission from your PCP. These are called self-referral
services and are listed below.
You DO NOT need a Referral to: See your PCP
Get care when you have an emergency
Receive services from your OB/GYN doctor in your network for routine or preventive services
(females only)
Receive Family Planning Services
Receive services for sexually transmitted diseases (STDs)
Receive Immunizations (shots)
Visit a vision provider in the network
Take your child to a dental provider in the network
Receive emergency mental health or services for problems with alcohol or other drugs
Receive up to 10 mental health sessions (A treatment plan is required after 10 visits.)
Mental Health Services
Mental health care is for both adults and children. This care helps when you feel depressed or anxious.
If you need help, or someone from your family needs help, call
The D.C. Department of Behavioral Health Hotline at 1-888-793-4357, 24 hours a day, 7 days a
week
You can get up to 10 mental health Appointments without a Referral.
Services for alcohol or other drug problems Problems with alcohol or other drugs are dangerous to your health and can be dangerous to the health of
people around you. It is important to go to the doctor if you need help with these problems. Trusted will
help you arrange for detoxification services and provide care coordination to help you get other services.
To get services for these problems, you can:
Call Member Services at (202) 821-1100 or (855) 326-4831 (toll free), 24 hours a day, 7 days a
week.
Call APRA directly at (202) 727-8473.
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Birth control and other Family Planning Services
You can get birth control and other Family Planning Services from any provider you pick. You may choose
an “out of network” provider. You do not need a referral to get these services. If you choose a Family
Planning Services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you.
Talk to your PCP or call Trusted Member Services at (202) 821-1100.for more information on birth control
or other Family Planning Services.
All birth control and other Family Planning Services are confidential.
Family Planning Services include:
Pregnancy Testing
Counseling for the Woman and the Couple
Routine and Emergency Contraception
Counseling and Immunizations
Screening for all Sexually Transmitted Diseases
Treatment for all Sexually Transmitted Diseases
Sterilization Procedures (Requires you to sign a form 30 days before the procedure)
HIV/AIDS Testing and Counseling
Family Planning Services do not include:
Routine infertility studies or procedures
Hysterectomy for sterilization
Reversal of voluntary sterilization
HIV/AIDs Treatment
Abortion Services
HIV/AIDS testing, counseling and treatment
You can get HIV/AIDS testing and counseling:
When you have Family Planning Services
From your PCP
From an HIV testing and counseling center
For information on where you can get for HIV testing and counseling, call Member Services (202)
821-1100. If you need HIV treatment, your PCP will help you get the care you need.
You do NOT need a Referral to receive birth control or other Family Planning
Services.
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Pharmacy Services and prescription drugs Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must
go to a pharmacy in Trusted’s network. Trusted’s network includes most pharmacies in the District.
You can find the full list of pharmacies in the Trusted network online at www.Trustedhp.com
If you are out of town and you have an emergency or need Urgent Care and need a prescription filled, just
contact our Member Services Department or Nurse Help Line (855) 872-1852 (toll free).
To get a prescription filled:
Pick a pharmacy that is part of the Trusted network and is close to your work or home.
When you have a prescription, go to the pharmacy and give the pharmacist your prescription and
your Trusted Member ID Card.
If you need help, please call Member Services at (202) 821-1100.
Things to remember:
You should not be asked to pay for your medicines. Call Trusted Member Services if the
pharmacy or drug store asks you to pay.
Sometimes, your doctor may need to get permission from Trusted for a drug. While your doctor is
waiting for the permission, you have a right to get the medication:
For up to 72 hours OR
For one full round of the medicine if you take it less than once a day
Case Management and Disease Management
If you have a chronic illness or special health care need such as asthma, high blood pressure or mental
illness, you may be eligible for our Case Management or Disease Management Program. This means you
will have a Care Manager. A Care Manager is someone who works for Trusted and who will help you get
the services and information you need to manage your illness and be healthier. Your doctor can refer you
for this program using the form at http://www.trustedhp.com/referrals.html. You can refer yourself or a
family member by calling Member Services at (202) 821-1100.
Services to Keep Adults from Getting Sick Trusted wants you to take care of your health. We also want you to sign up for health and wellness
services we offer to you. Health and wellness services include screenings, counseling and immunizations.
Recommendations for Checkups (“Screenings”) Please make an appointment and go see your PCP at least one time every year for a checkup. The list below
tells you the type of things to talk with your PCP about during your checkup.
Please make an appointment to see your PCP at least once a year for a checkup.
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Preventive counseling Preventive counseling is available to help you stay healthy. You can get preventive counseling on:
Diet and exercise
Alcohol and drug use
Smoking cessation
HIV/AIDS prevention
Obesity
Adult Immunizations
If you are an adult, you may need some immunizations (shots). Please talk to your PCP about which ones
you may need.
Pregnancy If you are pregnant or think you are pregnant, it is very important that you go to your OB/GYN doctor right
away. You do not need to see your PCP before making this appointment.
If you are pregnant, please call:
Adult Screening Recommendations
Blood pressure and cholesterol (lipid
disorder) Screening
Sexually transmitted diseases
HIV/AIDS Screening & testing
Diabetes Screening
Tobacco Use
Alcohol and Other Drug Use
Depression
Colorectal Cancer (50 years and older)
Obesity
Hepatitis C
Screenings for Women Only
Breast cancer Screening
(mammogram)
Cervical Cancer
Osteoporosis
(post-menopausal women)
HPV Screening
Chlamydia
Screenings for Men Only
Prostate cancer Screening
Abdominal Aortic Aneurysm
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Your ESA Caseworker at 202-727-5355
Member Services at 202- 821-1100 or (855) 326-4831 (toll free).
Your PCP
There are certain things that you need to get checked if you are pregnant. These will help make sure that
you have a healthy pregnancy, delivery, and baby. This is called prenatal care. You get prenatal care before
your baby is born.
Remember, if you are pregnant or think you are pregnant do not drink alcohol, use drugs or smoke.
Prenatal and Post-Partum Care When you register with Trusted’s OB hotline, you get these services:
Pregnancy Case Manager
Assistance obtaining WIC
Prenatal Information & Classes
Once you have had your baby, call:
Member Services
Your Trusted OB Case Manager and
Your ESACaseworkerYour Child’s Health
Health Check Program for Children (EPSDT) Trusted wants to help your children grow up healthy. If your child is in the D.C. Healthy Families
(Medicaid) program, your child will be in the Health Check Program, also called Early and Periodic
Screening, Diagnosis and Treatment (EPSDT). This program starts right after your child is born and lasts
until your child turns 21. The Health Check Program gives your child a number of important checkups.
There is a Health Check (EPSDT) information sheet in this handbook. You can also ask your doctor, call
Member Services, or visit our website www.Trustedhp.com for a copy of the Health Check (EPSDT)
Periodicity Schedule. The schedule tells you when your child needs to go to the doctor.
In addition to Health Check/EPSDT services, your child can also get the benefits described in the “Member
Health Benefits” section below.
Immigrant Children
If your child is in the Immigrant Children’s Program, your child will get well-child care. This program starts
right after your child is born and lasts until your child turns 21.
In addition to well-child care, your child can also get the benefits described in the “Member Health
Benefits” section below.
You do not have to pay anything for these Services for your child – they are free. If
you have any questions or need help with transportation or scheduling an
appointment, please call Member Services.
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Care for your children’s teeth All dental health checkups and treatments are free for Trusted Members under age 21.
Dentists can prevent cavities and teach you and your child how to care for their teeth.
From birth up to age 3, your child’s PCP may provide dental care during regular check-ups. The PCP
may decide to send the child to a dentist.
Beginning at age 3, all children should see a dentist in the Trusted network for a checkup every year.
Look in Trusted’s Provider Directory or online at www.Trustedhp.com to pick a dentist near you. Please
call the dentist’s office for an appointment.
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Children with Special Health Care Needs When children have -- or are at risk of having -- physical, developmental, behavioral, or emotional
conditions that are permanent or that last a long time, they can have Special Health Care Needs. These
children may need health care and other services that are more than or different from what other children
need.
Trusted will check to see if your child has Special Health Care Needs. Please be sure your child has been
checked for this. If your child has not been checked to see if they have special healthcare needs, call
Member Services at (202) 821-1100.
If your child has Special Health Care Needs, your child has the right to have a PCP who is a specialist
Be sure your child with a special health care need has a Treatment Plan. Call Trusted Member Services
to ask for a treatment plan for your child.
The IDEA program
IDEA stands for the Individuals with Disabilities Education Act. IDEA is a federal law. The IDEA program
provides special services for your child with developmental delays, disabilities or special needs. Children up
to age 3 get early intervention services from Trusted. Children age 3 and older get special educational
services from the D.C. public school system.
For more information please contact Member Services at (855) 326-4831
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Growth Chart:
Here are some of the things that you should be looking for as your child grows. Every child develops at his
or her own pace. Your child may reach these milestones slightly before or after other children of the same
age. Use this as a guide. If you have any concerns, talk to your child’s doctor.
By the end of 7 months, many children are able to:
Turn head when name is called
Smile back at another person
Respond to sounds with sounds
Enjoy social play (such as peek-a-boo)
By the end of 2 years (24 months), many children are able to:
Use 2- to -4 word phrases
Follow simple instructions
Become more interested in other children
Point to an object or picture when named.
By the end of 1 year (12 months), many children are able to:
Use simple gestures (waving “bye-bye”)
Make sounds such as “ma” and “da”
Imitate actions in their play (clap when you clap)
Respond when told “no”
By the end of 3 years (36 months), many children are able to:
Show affection for playmates
Use 4- to- 5 word sentences
Imitate adults and playmates (run when other children run)
Play make-believe with dolls, animals, and people (“feed” a teddy bear)
By the end of 1 ½ years (18 months), many children are able to:
Do simple pretend play (“talk” on a toy phone)
Point to interesting objects
Look at object when you point at it and tell them to look
Use several single words unprompted
By the end of the 4 years (48 months)many children are able to :
Use 5- to 6- word sentences
Follow 3-step commands (“Get dressed, comb your hair and wash your face”)
Cooperate with other children
If you think your child is not growing the way he or she should, have your child tested (“IDEA evaluation”).
To get an IDEA evaluation, call your PCP. If your child needs IDEA Services, your PCP will refer your
child to the D.C. Government’s Early Intervention Program. Trusted has case managers who can tell you
more about IDEA and the other services your child can get.
Trusted covers the services listed below if your child is in the IDEA program: For children up to age 3, Trusted covers all health care services even if the service is in your
child’s treatment plan.
For children aged 3 and older, Trusted:
Pays for all health care services and services in your child’s treatment plan that your
child needs when not in school—even on evenings, weekends and holidays.
Coordinates services that are not provided through the school’s treatment plan.
For more information on the services your child can get through the IDEA program, contact your child’s school.
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Immunizations (shots) for children and teens Immunizations (shots) are important to keep your child healthy! When your child is very young, your
child will need shots every few months. The shots start at birth. These shots protect them from diseases.
Your PCP and Trusted will schedule appointments for your child’s shots.
Shots are free. The shot schedule for children is:
AGE IMMUNIZATION
Birth HepB #1
2 months HepB#2, DTaP#1, RV#1, Hib#1,
PCV#@1, IPV#1
4 months DTaP#2, RV#2, Hib#2, PCV#2, IPV#2
6 months HepB#3, Hib#3, DTaP#3, RV#3,
PCV#3, IPV#3
12 months HiB#4, MMR#1, Varicella#1, PCV#4,
HepA#2
15 months Varicella #2
18 months Hep A#2
4 years-6 years DTAP, MMR, IPV
13 years or older Varicella
11 years-12 years HPV (girls only), MCV4
13 years – 18 years Tdap, HPV
18 years or younger MCV4
Every Year Beginning at 6 months, Seasonal
Influenza (“flu”) vaccine as
recommended each year
Your Health Benefits
Health Services covered by Trusted
The list below shows the health care services and benefits for all Trusted Members. For some benefits, you
have to be a certain age or have a certain need for the service. You may need a Prior Authorization for the
service. Trusted will not charge you for any of the health care services in this list if you go to a network
provider or hospital. You will not have a co-pay, or need to file a claim.
If you have a question about whether Trusted covers certain health care, call Trusted Member Services at
(202) 821-1100.
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BENEFIT WHAT YOU GET
WHO CAN GET THIS
BENEFIT
Primary Care Services Preventive, acute, and chronic health care
Services generally provided by your PCP All Members
Specialist Services
Health care Services provided by specially
trained doctors or advanced practice nurses.
Referrals are usually required
Does not include cosmetic Services and
surgeries except for surgery required to correct
a condition resulting from surgery or disease,
created by an accidental injury or a congenital
deformity, or is a condition that impairs the
normal function of your body
All Members
Laboratory &
X-ray Services Lab tests and X-rays All Members
Hospital Services
Outpatient Services (preventive, diagnostic,
therapeutic, rehabilitative, or palliative
Services)
Inpatient Services (hospital stay)
Any Member with a Referral
from their PCP or who has an
emergency
Pharmacy Services
(prescription drugs)
Prescription drugs included on the Trusted
drug formulary. You can find the drug
formulary at www.Trustedhp.com or by
calling Member Services.
Only includes medications from network
pharmacies
Includes the following non-prescription (over-
the-counter) medicines:
- Fever and Pain relievers like Tylenol or
Advil
- Sinus and Allergy Medicines like
Benadryl
- Cough and Cold Medicines
- Hydrocortisone 1% for Rashes
All Members other than
dually
eligible(Medicaid/Medicare)
Members whose prescriptions
are covered under Medicare
Part D
Emergency Services
A Screening exam of your health condition
and stabilization if you have an Emergency
Medical Condition, regardless if the Provider
is in or out of the Trusted network.
Treatment for emergency conditions
All Members
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BENEFIT WHAT YOU GET
WHO CAN GET THIS
BENEFIT
Family Planning
Pregnancy Testing: Counseling for the woman
Routine and Emergency Contraception
Voluntary sterilizations for Members over 21
years of age (requires signature of an approved
sterilization form by the Member 30 days prior
to the procedure)
Screening, Counseling and Immunizations
(including for HPV)
Screening and preventive treatment for all
sexually transmitted diseases
Does not include sterilization procedures for
Members under age 21
All Members as appropriate
Podiatry
Special care for foot problems
Regular foot care when medically needed.
All Members
Rehabilitation
Services
Rehabilitation Services, including physical,
speech and occupational therapy All Members
Prosthetic devices Replacement, corrective, or supportive devices
prescribed by a licensed provider All Members
Vision Care
Eye exams at least once every year and as
needed; and eye glasses (corrective lenses) as
needed
Members under age 21
Home Health Services
In-home health care Services, including:
Nursing and home health aide care
Home health aide Services provided by a
home health agency
Physical therapy, occupational therapy, speech
pathology and audiology Services
All Members
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BENEFIT WHAT YOU GET
WHO CAN GET THIS
BENEFIT
Nursing Home Care Full-time skilled nursing care in a nursing
home up to 30 consecutive days
All Members
Hospice Care Support Services for people who are dying All Members
Adult Wellness
Services
Immunizations
Routine Screening for Sexually Transmitted
Diseases
HIV/AIDS Screening, testing and counseling
Breast cancer Screening (women only)
Cervical cancer Screening (women only)
Osteoporosis Screening (post-menopausal
women)
HPV Screening (women only)
Prostate cancer Screening (men only)
Abdominal aortic aneurysm Screening (men
only)
Screening for obesity
Diabetes Screening
Screening for high blood pressure and
cholesterol (lipid disorders)
Screening for depression
Colorectal cancer Screening (Members 50
years and older)
Smoking cessation counseling
Diet and exercise counseling
Mental Health counseling
Alcohol and drug Screening
Members over age 21 as
appropriate
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BENEFIT WHAT YOU GET
WHO CAN GET THIS
BENEFIT
Child Wellness
Services
Whatever is needed to take care of sick children
and to keep healthy children well, including
Screening and assessments such as:
Health and development history and
Screenings
Physical and mental health development and
Screenings
Comprehensive health exam
Immunizations
Lab tests including of blood lead levels
Health education
Dental Screening Services
Vision Screening Services
Hearing Screening Services
Alcohol and drug Screening and counseling
Mental health Services
Does not include any health Services furnished to
a child in a school setting
Members under age 21
Dental Benefits
General dentistry (including regular and
emergency treatment) and orthodontic care for
special problems
Check-Ups twice a year with a dentist are
covered for children ages 3 through 20.
A child’s PCP can perform dental Screenings
for a child up to age 3
Does not include routine orthodontic care
Members under age 21
(Members 21 years and older
can get dental services from
Medicaid. Call MCO Dental
Help Line at 1-866-758-
6807)
Hearing Benefits
Diagnosis and Treatment of conditions related to
hearing, including hearing aids and hearing aid
batteries
All Members
Alcohol & Drug
Abuse Treatment
Inpatient detoxification
Other alcohol/drug abuse services are
provided by the Addiction, Prevention and
Recovery Administration (APRA)
Help with getting care from APRA
All Members
Inpatient and outpatient substance abuse
treatment
Other alcohol/drug abuse Services are
provided by the Addiction, Prevention and
Recovery Administration (APRA)
Help with getting care from APRA
Members under age 21
Dialysis Hemodialysis
Peritoneal Dialysis All Members
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BENEFIT WHAT YOU GET
WHO CAN GET THIS
BENEFIT
Durable Medical
Equipment (DME) &
Disposable Medical
Supplies (DMS)
Durable Medical Equipment (DME)
Disposable medical supplies (DMS) All Members
Services We Do Not Pay For Exclusions are benefits and/or services that are not paid for by Trusted or DC Medicaid. They include the
following:
Acupuncture
Alcohol and other drug abuse services
Chiropractic Services
Cosmetic surgery
Deliveries (if you are pregnant, contact the Economic Security Administration (ESA) at (202)727-
53555 to determine eligibility for Medicaid. Deliveries are covered by Medicaid
Experimental or investigational services, surgeries, treatments, and medications
Hearing services for members over 21
Services that are part of a clinical trial protocol
Abortion, or the voluntary termination of a pregnancy, not required under Federal law
Infertility treatment
Open heart surgery
Organ Transplant
Private Duty Nursing
Sclerotherapy services and items
Sterilizations for persons under the age of 21
Services that are not medically necessary
Screening and stabilization services for emergency and medical conditions outside of the network
including inside the District. You will be responsible for the charges for the out of network services
including emergency services.
Treatment for obesity
Vision services for members over 21
Any covered services when furnished by providers that are not members of the Network.
Services that are NOT medically necessary
Non – emergency transportation services.
After clinical review based on scientific evidence, new technology is evaluated by Trusted for inclusion as a
covered benefit. Technology assessment decisions are published in the form of medical policies and are
posted to our website for your doctor to access and use in their practice. In addition, members may request a
copy of a medical policy by contacting our Member Services at (202) 821-1100. All existing medical
policies are reviewed at least annually and updated accordingly.
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Other Important Information
What to do if you move
Call the District of Columbia (DC) Economic Security Administration (ESA) Change Center at 202-
727-5355.
Call Trusted Member Services at (202) 821-1100.
What to do if you have a baby
Call DC Economic Security Administration (ESA) Change Center at 202-727-5355.
Call Trusted Member Services at (202) 821-1100 or (855) 326-4831 (toll free)
What to do if you adopt a child
Call DC Economic Security Administration (ESA) Change Center at 202-727-5355.
What to do if someone in your family dies
Call DC Economic Security Administration (ESA) Change Center at 202-727-5355.
Call Trusted Member Services at (202) 821-1100.
How to change your Managed Care Organization You can change your MCO once a year, or at any time if you have a good reason.
You can change your MCO once a year during the 90 days before your anniversary date—the month and
date you first joined Trusted.
D.C. Healthy Families will send you a letter two months before your anniversary date. The letter tells you
how to change MCOs.
Call ESA at 202-727-5355 and Member
Services at (202) 821-1100 if:
You move
You have a baby
If you adopt a child
Someone in your family dies
Call ESA only at 202-727-5355 if:
You adopt a child
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You will not be allowed to get health care from Trusted anymore if you:
Lose your Medicaid eligibility
A child will be removed from Trusted if the child:
Becomes a ward of the District
The D.C. government may remove you from Trusted if you:
Let someone else use your Member ID Card;
The District finds you committed Medicaid fraud
You do not follow your Member responsibilities.
What to do if you get a bill for a covered service If you get a bill for a covered service that is in the list above, call Member Services at (202) 821-1100.
Paying for Non-Covered Services If you decide to get a service that we do not pay for, you must sign a statement that you agree to pay
for the service yourself.
Remember to always show your Member ID Card and tell doctors that you are a Member of Trusted
before you get services.
Advance directives
An advance directive can let you pick a person to make choices about your medical care for you. An
advance directive also lets you say what kind of medical treatment you want to receive if you become too ill
to tell others what your wishes are.
Changing Your MCO If You Have a Good Reason
You have the right to change your MCO at any time after the first 90 days if you have a good reason.
Examples of good reasons are poor quality of care and you can’t see the providers you need. Call DC
Healthcare Alliance at 202-639-4030 if you would like more information on how to change MCOs. You
may also contact the Enrollment Broker (ESA) to request the change to a new Health Plan at (202) 727-
5355.
An advance directive is a legal document you sign that lets others know your health care
choices. It is used when you are not able to speak for yourself. Sometimes this is called a
“living will” or a “durable power of attorney.”
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It is important to talk about an advance directive with your family, your PCP, or others who might
help you with these things.
If you want to fill out and sign an advance directive, ask your PCP for help during your next
appointment, or call Member Services at (202) 821-1100 and they will help you.
Trusted will tell you about any changes in District law about advance directives within 90 days.
What to do if you have other insurance
If you are a Member of Trusted and eligible for Medicaid, you must tell us right away if you have any other
health insurance. Please call Member Services at (202) 821-1100 and tell us right away.
What to do if you are eligible for both Medicaid and Medicare If you have Medicare and Medicaid, please tell Trusted so you can pick Medicare providers. If you have
Medicare, you will have to sign up for Medicare Part D for your prescription drugs. Medicaid will pay your
co-pays. See page 44 of this handbook for more information.
Physician (doctor) incentive plan disclosure
You have the right to find out if Trusted has special financial arrangements with Trusted’s doctors.
Please call Trusted Member Services at (202) 821-1100 for this information.
Complaints/Grievances, Appeals and Fair Hearings Trusted and the D.C. government both have ways that you can complain about the care you get or the Services
Trusted provides to you. You may choose how you would like to complain as described below.
Complaints/Grievances If you are unhappy with something that happened to you, you can file a Complaint/Grievance.
Examples of why you might file a Complaint/Grievance include:
You feel you were not treated with respect
You are not satisfied with the health care you got
It took too long to get an Appointment
To file a Complaint/Grievance, you should call Member Services at (202) 821-1100 or (855) 326-
4831 (toll free).
To file a written Complaint/Grievance, send to
Trusted Health Plan
1100 New Jersey Ave., SE Ste. 840
Washington, DC 20003
Your doctor can also file a Complaint/Grievance for you. If your doctor files the complaint for you,
you need to give them permission in writing.
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You should file a Complaint/Grievance as soon as possible and no later than 90 days after the event or thing
that makes you unhappy. Trusted will usually give you a decision within 30 days but may ask for extra
time (but not more than 44 days total) to give a decision.
Appeals and Fair Hearings If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an
Appeal with Trusted and request a “Fair Hearing” with the D.C.’s Office of Administrative Hearings.
To file an Appeal with Trusted call Member Services at (202) 821-1100.
To file a request for a Fair Hearing, call or write the District government at:
District of Columbia Office of Administrative Hearings
Clerk of the Court
441 4th Street, NW
Suite 450 – North
Washington, DC 20001
Telephone Number: 202-442-9094
Deadlines
You must file an Appeal or request a Fair Hearing within 90 days of getting Trusted’ s
notice of action.
If you want to continue receiving the benefit during your Fair Hearing or Appeal, you
must request the Fair Hearing or Appeal by the following:
Within 15 days from Trusted postmark of the Notice of Action or
The intended effective date of Trusted’s proposed action (or, in other words, when
the benefit is to stop).
Your provider may file an Appeal or request for a Fair Hearing on your behalf. You will need to
request this is writing.
Appeals If you call and give your Appeal over the phone, Trusted will summarize your Appeal in a letter and
send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and
return it to the Trusted in order to have an Appeal.
Your Appeal will be decided by Trusted within 14 calendar days from the date your Appeal was
received.
If Trusted needs more time to get information and the District decides this would be best for you, or
if you or your Advocate requests more time, Trusted may increase this time period for the decision
by 14 calendar days. Trusted must give you written notice of the extension.
You will receive written notice of Trusted’s decision about your Appeal in the mail.
If you are not happy with Trusted’s decision about your Appeal you may request a Fair Hearing.
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Expedited (Emergency) Complaints/Grievances and Appeals process If your Appeal is determined to be an emergency, Trusted will give you a decision within 3 calendar days.
An Appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the
standard time frame of the Appeal procedure.
All Appeals filed by Members with HIV/AIDS, mental illness or any other condition that requires attention
right away, will be resolved and communicated back to the Member within 24 hours of filing the Appeal.
Your rights during the Complaints/Grievances, Appeals and Fair Hearings process
You have the right to a Fair Hearing. You may request a Fair Hearing from the Office of
Administrative Hearings at any time before, during or after you have filed an Appeal with Trusted,
but no more than ninety (90) days from the date Notice of Action is mailed.
You have a right to keep receiving the benefit we denied while your Appeal or Fair Hearing is being
reviewed. To keep your benefit during a Fair Hearing, you must request the Fair Hearing within a
certain number of days - This could be as short as 10 days.
You have the right to have someone from Trusted help you through the Grievance and Appeals
process.
You have a right to represent yourself or be represented by your family caregiver, lawyer, or other
representative.
You have a right to have accommodations made for any special health care need you have.
You have a right to adequate TTY/TTD capabilities, and Services for the visually impaired.
You have a right to adequate translation Services and an interpreter.
You have a right to see all documents related to the Complaint/Grievance, Appeal or Fair Hearing.
You have a right to present evidence in person or in writing. If it is an expedited (emergency)
appeal, you must do it within the 3 day timeframe.
If you have any questions about the Complaints/Grievances and Appeals/Fair Hearings process, please call
Member Services at (202) 821-1100.
The District’s Ombudsman Program
The Ombudsman Program is a District of Columbia government program that provides assistance and
advice to you in receiving health care from your MCO. The Ombudsman can:
Explain the health care you have a right to receive;
Respond to your questions and concerns about your health care;
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Help you understand your rights and responsibilities as an Enrollee in an MCO;
Provide assistance in getting you the health care you are supposed to have;
Answer questions and concerns you may have about the quality of your health care;
Help you resolve problems with your doctor or other health care provider; and
Provide assistance in resolving complaints and problems with Trusted; and
Assist with the appeal process.
To reach the Ombudsman Program, call 202-724-7491 or 1-877-685-6391 (Toll Free).
The Ombudsman Program does not make decisions in grievances/complaints, appeals or fair hearings.
The Office of Health Care Ombudsman & Bill of Rights is located at:
899 North Capitol Street, N.E. – 6th Floor
Washington, D.C. 20002
(202) 724-7491 (OFFICE) (202) 535-1216 (FAX) 1 (877) 685-6391 (TOLL FREE)
[email protected] (E-MAIL)
www.healthcareombudsman.dc.gov (WEBSITE)
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Notice of Privacy Practices This Notice describes how medical information about you may be used and disclosed, and how you can
get this information. Please read it carefully.
Why Are You Giving This Notice to Me?
Trusted Health Plan knows that information about you and your health is personal, and we are required
by the federal Health Insurance Portability and Accessibility act (HIPAA) to tell you what your
responsibilities are and what rights you have under the law. Trusted Health Plan has internal
procedures to protect oral, written and electronic protected health information across the organization.
What is Trusted Health Plan Required to do Under HIPAA?
Make sure that your protected health information is kept private;
Give you this notice to tell you about our legal duties and privacy practices with respect to your PHI;
and
Follow the terms of this notice.
What is Protected Health Information (PHI) Protected Health Information (PHI) is defined as any oral, written or electronic information that:
Identifies you or can be used to identify you.
Either comes from you or has been created or received by a health care provider, a health plan, or a
healthcare clearinghouse.
Has to do with your physical and/or mental health or condition, providing health care to you, or paying
for providing health care to you.
In this notice, “protected health information” will be written as PHI.
How Can You Use or Share my PHI? There are laws that allow or require us to use or disclose your PHI for many reasons. This Notice tells you
how we may use and disclose your PHI. While not every use or disclosure is listed, the ways we may use to
share your PHI falls within one of the descriptions below.
For Treatment:
We may use and share your PHI for treatment. For example, we may use or share your PHI to enroll you in
a disease management program, or to share it with your case manager.
For Payment to Caregivers:
We may use and share your PHI in order to pay for health care you receive. For example, a bill that we may
receive from your doctor may have information on it that identifies you, the nature of your illness, the
treatment or tests given to you and the supplies that might have been used.
For Health Care Operations:
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We may use and share your PHI to run our business. We protect your PHI by limiting access to it within our
Plan. Only our employees directly involved in our business activities that require access to your PHI are
authorized to see or discuss your PHI. For example, we may use your PHI to review and improve the quality
of healthcare services you receive. In addition, Trusted shares your PHI with our business partners; however,
they are under the same obligations to protect your PHI as Trusted is.
For Another Covered Entity’s Needs:
We may share your PHI with another covered entity, such as a doctor or health plan, for their treatment or
payment use. For example, we may share your PHI with a health plan to help them pay for your care. We
may also share your PHI with them so that they can do certain business tasks if you have or have had a
relationship with them.
To remind you of appointments and health-related benefits or services:
We may use your PHI to send you appointment reminders. We may use PHI to tell you about other health
care treatment, services, or benefits.
To comply with the law:
We will share your PHI when we are required by law to do so. We will share PHI when we are required to
in a court or other legal proceeding. For example, we will disclose PHI if a law says that we must report PHI
about people who have been abused.
To report public health activities:
We will share PHI with government officials in charge of collecting certain PHI. For example, we may share
PHI about births, deaths, and some diseases.
For health oversight activities:
We may share PHI if a government agency conducting activities approved or required by law, such as audits,
investigations, licensure or disciplinary actions. Oversight agencies include government agencies that look
after the health care system, benefit programs, including Medicaid, SCHIP, or Healthy Kids, and government
regulation programs.
For purposes of disposition of your remains:
We may share your PHI with coroners, medical examiners, and funeral directors. If permitted by law, we
may also share PHI with organizations that help find organs, eyes, and tissue to be donated or transplanted.
To avoid harm:
In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law
enforcement or others who may be able to stop or lessen the harm.
For certain government functions:
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We may share PHI for national security reasons. For example, we may share PHI to protect the President of
the United States.
For Workers’ Compensation:
We may share PHI to obey workers’ compensation laws.
Lawsuits and disputes:
If you are involved in a lawsuit or a dispute, we may share PHI about you in response to a court or
administrative order or other lawful process.
For research:
We may share your PHI with researchers when an institutional review board or privacy board as followed
the HIPAA information requirements.
Other Uses and Sharing of Your Health Information:
We will ask for your written permission, before we make any use or disclosure of your PHI not described
in this notice. If you give us your written permission, you may still decide later that you no longer want us
to use or disclose your PHI in that way. If you change your mind, you must tell us in writing. We will then
stop using your PHI in that way.
Will You Give my PHI to my Family, Friends, or Others?
We may share PHI about you with a friend or family member who is involved with your care or who helps
pay for your care when you are present if you agree to do so. For example, if one of our case managers
visits you in the hospital and your mother is with you, we may discuss your PHI with you in front of her if
you approve. We will not discuss your PHI with others unless you have given permission. There may be
times when you are not present or are unable to make healthcare decisions. If this should happen, we may
share your PHI with the next of kin or a relative you have given permission for us to speak for you. For
example, we may share PHI with your emergency contact on file if you are unable to speak, so that you can
receive care.
What are my Rights Under Federal Law with Respect to my PHI? The law gives you the following rights regarding your PHI. To receive these rights, please call Member
Services.
1. You can see or get copies of some of your PHI – Sometimes your right to see or get copies of your
PHI may be limited. You must ask us in writing. We may charge a fee for copying and mailing the
PHI.
2. You may ask us to limit our uses and disclosures for purposes of treatment, payment or
healthcare operations. – We are not required to agree to the request. You may also ask us to limit
disclosures to someone who is involved in our care or payment for your care, like a family member
or friend.
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3. You may ask us to send your PHI to another address if it is necessary to protect you from
danger. You may ask us to communicate with you in a certain way if it is necessary to protect
you from danger. – For example, you may ask us to send PHI to you at work instead of at home.
You may ask us to send your PHI by e-mail rather than regular mail. You must tell us in writing
what you want. You must tell us that you could be in danger if we do not agree to your request.
4. You can get a list of certain disclosures we have made of your PHI. – The list will only include
disclosures made after April 14, 2003. The list will not include certain types of disclosures. We will
give you one list free during any 12 month period. You will need to pay for any additional lists
during that time.
5. You may ask us to correct your PHI if you think there is a mistake. You must ask us in writing
and tell us why you want us to correct the information.
6. You may get a paper copy of this notice at any time. To obtain a paper copy of this notice, please
call Member Services.
May I Complain about Your Privacy practices? Yes! YOU WILL NOT BE PUNISHED FOR FILING A COMPLAINT. If you think we violated your
privacy rights you may file a complaint. You must send your written complaint to:
Trusted Health Plan
1100 New Jersey Ave., SE
Ste. 840
Washington, DC 20003
You may send a written complaint to the Secretary of the Department of Health and Human Services
(DHHS) at:
Office for Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
You may also call DHHS at (877) 696-6775.
How will I know if my rights change? We may change this notice and our privacy policies at any time. Then the new notice will apply to all of
your PHI. We will make the new notice available to you at all times. The new notice will contain the new
effective date.
If you have any questions about this notice, please contact Member Services at (202) 821-1100.
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What Some Words Mean Advance Directive A written, legal paper that you sign that lets others know what health
care you want, or do not want, if you are very sick or hurt and cannot
speak for yourself
Advocate A person who helps you get the health care and other Services you need
Appeal An appeal is a special kind of complaint you make if you disagree with a
decision Trusted makes to deny a request for health care services or
payment for services you already received. You may also make this kind
of complaint if you disagree with a decision to stop services that you are
receiving
Appointment A certain time and day you and your doctor set aside to meet about your
health care needs
Care Manager Someone who works for Trusted and will help those people in the
Disease Management Program get the care and information they need to
stay healthy
Check-Up See Screening
Complaint See Grievance
Contraception Birth control
Covered Services Health care Services that Trusted will pay for
Detoxification Getting rid of harmful substances from the body such as drugs and
alcohol
Development The way in which your child grows
Disease Management Program A program to help people with chronic illnesses or Special Health Care
Needs such as asthma, high blood pressure or mental illness get the care
and Services they need
Durable Medical Equipment Special medical equipment that your doctor may ask or tell you to use in
your home
Emergency Care Care you need right away for an Emergency Medical Condition.
Emergency Medical Condition A serious, sudden, sometimes life-threatening condition
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EPSDT Early, Periodic Screening, Diagnosis and Treatment Program (also called
Health Check Program) that gives health care to members under 21
years old
Fair Hearing If you file a Grievance/Complaint you can ask for a hearing with D.C.'s
Office of Administrative Hearings
Family Planning Services such as pregnancy tests, birth control, testing and treatment for
sexually transmitted diseases, and HIV/AIDs testing and counseling
Family and General Practice
Doctor
A doctor that can treat the whole family
Grievance If you are unhappy with the care you get or the health care services
Trusted gives you, you can call Member Services to file a
Grievance/Complaint
Handbook This book that gives you information about Trusted and our services
Health Check Program See EPSDT
Hearing Impaired If you cannot hear well, or if you are deaf
IDEA Individuals with Disabilities Education Act; a federal law that gives
services to children with developmental delays and special health care
needs
Immunization Shot, vaccine
Internal Medicine Doctor Doctor for adults and children over 14 years old
Interpretation/Translation
Services
Help from Trusted when you need to talk to someone who speaks your
language, or you need help talking with your doctor or hospital
Managed Care Organization
(MCO)
A company that is paid by the District of Columbia to give you health
care and health services
Managed Care Plan A plan that gives you a list of Providers that you can see
Maternity The time when a woman is pregnant
Member The person who gets health care from Trusted
Member Identification Card The card that lets your doctors, hospitals, drug stores, and others know
that you are a member of Trusted
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Mental Health How a person thinks, feels and acts in different situations
Network Providers Doctors, nurses, dentists, and other people who take care of your health
who are a part of Trusted
Non-Covered Services Health care that Trusted does not pay for
OB/GYN Obstetrician/Gynecologist; a doctor who is trained to take care of a
woman’s health, including when she is pregnant
Out-of-Network Providers Doctors, nurses, dentists, and other people who take care of your health
who are not a part of Trusted
Pediatrician A children's doctor
Pharmacy The store where you pick up your medicine
Physician Incentive Plan Tells you if your doctor has any special arrangements with Trusted
Post Partum Care Health care for a woman after she has her baby
Post-Stabilization Care Health care to stabilize a patient after an emergency
Prenatal Care Care that is given to a pregnant woman the whole time she is pregnant
Prescription The order that your doctor writes for Medicine; you must take it to the
pharmacy/drugstore to pick up the medicine.
Preventive Counseling When you want to talk to someone about ways to help you stay healthy
or keep you from getting sick or hurt
Primary Care Provider (PCP) The doctor that takes care of you most of the time
Prior Authorization Written permission from Trusted to get health care or treatment that is
not usually paid for by Trusted
Provider Directory A list of all providers who are part of the Trusted
Providers Doctors, nurses, dentists, and other people who take care of your health
Referral When your main doctor gives you a written note that sends you to see a
different doctor
Routine Care The regular care you get from your primary care provider or a doctor
that your primary care provider sends you to. Routine Care can be a
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Check-Up, physical, health screen, and regular care for health problems
like diabetes, asthma and hypertension
Screening A test that your doctor or other health care provider may do to see if you
are healthy. This could be a hearing test, vision test, or a test to see if
your child is developing normally
Self-Referral Services Certain services you can get without getting a written note or Referral
from your main doctor
Services The care you get from your doctor or other health care Provider
Special Health Care Needs Children and adults who need health care and other services that are
more than or different from what other children and adults need
Specialist A doctor who is trained to give a special kind of care like an ear, nose
and throat doctor or a foot doctor
Specialty Care Health care provided by doctors or nurses trained to give a specific kind
of health care
Sterilization Procedures A surgery you can have if you do not want children in the future
Transportation Services Help from Trusted to get to your appointment, which can include bus or
metro tickets, tickets to pay for a taxi, wheel chair vans, or ambulances.
The type of transportation you get depends on your medical needs
Treatment The care you get from your doctor
Urgent Care Care you need within 24 hours, but not right away
Visually Impaired If you cannot see well or you are blind