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

care

Allia

nce

Trusted Member Services (202) 821-1100 www.trustedhp.com

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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).

http://www.trustedhp.com/


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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:

[email protected]

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 checkup 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


24

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.


25

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

http://www.thrivehp.com/


30


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


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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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


32


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


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 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


Dialysis Hemodialysis

Peritoneal Dialysis All Members


33


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.


34

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


What to do if someone in your family dies


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


35

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.”


36

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


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.


37

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


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.


38

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;


39

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)

mailto:[email protected]

http://www.healthcareombudsman.dc.gov/


40

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


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


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

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