2023 Annual Notice to Maryland Physicians Care Members

Your Rights and Responsibilities

You can use all your member rights without being treated differently or losing health care services. It is important to know and understand your rights and responsibilities. They are listed in your Member Handbook or on our website at https://www.marylandphysicianscare.com/rights-and-responsibilities/. If you have any questions about your rights and responsibilities, call Member Services toll‐free at 1-800-953-8854.

Quality Improvement Programs Monitor Important Aspects of Care

We check on the quality of care you receive. Our Quality Improvement Program wants to make sure you have the following:

• Easy access to quality medical care.
• Health management programs that meet your needs.
• Help with any chronic conditions or illnesses you have.
• Support when you need it most, like after hospital admissions or when you are sick.
• High satisfaction with your health care providers and with the health plan.

Some examples of our quality improvement activities for you (and all our members) include:

• Sending you postcards or newsletters that help keep you up to date on your health care.
• Reviewing the quality of the service you get.
• Reminding you and your provider about preventive health care.
• Measuring standards, such as how long it takes to get an appointment.
• Monitoring to make sure your phone calls are answered as quickly as possible and that you get correct information.
• Making sure your providers have all the information they need to give you or your child good care.

This list does not include all our Quality Improvement Programs. To learn more about our Quality Improvement Programs, Health Management Programs, goals and our progress in meeting those goals, visit our website at https://www.marylandphysicianscare.com/quality-improvement/ or call us. We can also give you a written copy of all this information.

Maryland Physicians Care Values the Privacy and Security of Your Health Care Data

We have several safeguards in place to protect your health care data that include:

• Rules that tell us how we can use your health care data, whether it is written, verbal, or electronic. Staff is trained on these rules to keep your health care data protected.
• Locking your records and keeping your health care data in safe areas.
• Restricting access to your health care data. The only persons who have access to your data are those who need it to perform their job or provide care to you.

Your Privacy and Health Care Data Security Rights

• You have the right to agree or to object to how your health care data is used.
• When your health care data is used to give care to you, this is known as Treatment, Payment, and Health Care Operations (TPO).
• Without your permission, we will not use your health care data for any reason other than TPO.
• You may agree or object if you want your health care data to be used for any reason other than TPO. You must send MPC a request to have this done. We will make sure we have your permission.
• All requests must be in writing. You may send your written request to Compliance Manager, Maryland Physicians Care, 1201 Winterson Rd, 4th Floor, Linthicum Heights, MD 21090. You may cancel your request at any time.

You may contact us anytime with questions about your health care data or private information. You can also view the privacy policy on our website at https://www.marylandphysicianscare.com/privacy-policy/.

Approving Medically Necessary Health Care Through Utilization Management

We want to make sure our members receive the right health care in the right way at the right time. Our Utilization Management program monitors members’ use of services to see if health care services are being under- or over-used. We follow these principles:

• Medically necessary decisions are based only on appropriate care and service and the coverage provided.
• MPC does not reward practitioners or other individuals for issuing denials of coverage or care.
• MPC does not provide financial incentives to encourage decisions that result in underusing services.

Staff uses specific criteria to make these decisions. This includes clinical protocols, practice guidelines, and written policies. You can learn more about these clinical guidelines at https://www.marylandphysicianscare.com/providers/resources/. You may also call Member Services toll‐free at 1-800-953-8854 to request assistance from one of our utilization management staff.

Benefit or Copayment Questions

You can find information about your benefits and services (covered and non-covered), copays, and other charges in your Member Handbook or online at www.marylandphysicianscare.com/members/benefits/medical-coverage/. Make sure you know which services are included in your coverage and which are not. If you still have questions or want this information mailed to you, call Member Services toll‐free at 1-800-953-8854.

Population Health Management

MPC offers programs to help keep members healthy. These programs are provided as optional benefits, and you can choose to join or leave the programs at any time without any impact on your benefits.

Our Care Management Department is here to help you understand and control complex health conditions. We offer Care Management programs that can help you better manage your health. These programs educate you on your disease and give you tips on how to stay healthy. Care advisors and coordinators can help during normal business hours, Monday through Friday. A care advisor may be assigned to help you plan for and receive health care services. The care advisor also keeps track of what services are needed and what has been provided. It is your choice to participate in a Care Management program, and because this is an opt-in program, you can choose to join or leave the program at any time without any impact on your benefits. You can join or get more information by calling our Special Needs Coordinator toll-free at 1-800-953-8854 or by email at MBUMDMedicaidSpecialNeeds@marylandphysicianscare.com

MPC also offers self-management tools and resources to provide you with information to help you live a healthy life. These are available at https://www.marylandphysicianscare.com/members/health-and-wellness/.

Pharmacy

If you or your child needs medicine, we have a wide selection of approved drugs for your provider to choose from. This list identifies drugs available to you through a prescription from your provider. This list also includes generic prescription drugs, some brand name drugs, limits and/or requirements. Please ask your provider to consider a drug from the generic prescription drug list if it meets your medical needs.

New drugs may be added to the formulary. The formulary is updated monthly. If you have questions regarding prior authorization of medications, explanation of limits, process for generic substitution, or step therapies, visit https://www.marylandphysicianscare.com/members/benefits/approved-medications/.
If you need help or want this information mailed to you, please call Member Services toll‐free at 1-800-953-8854.

If You Receive a Bill from Your Provider

Under the HealthChoice Program, you are entitled to all covered medical services without cost. The covered services will be paid for by MPC or your other health insurance carrier if you have other primary insurance. Providers should not send you a bill for a covered medical service or for the difference between what your health insurance paid and what they charge (Balance Billing). Providers can only bill the amount they agreed upon with MPC. If you get a bill from one of our providers, call Member Services at 1-800-953-8854 for help.

How to Choose the Care You Need

Your primary care provider (PCP) is a central part of your health care. He or she should be the one you contact first for most issues and hospital services.

Sometimes you or your child may need care from a specialist that treats specific conditions. Your PCP can recommend a specialist for you. You also have the option of finding your own provider. Check their professional credentials, like board certifications, in your provider directory. You can visit the MPC’s online provider directory at https://www.marylandphysicianscare.com/find-a-provider/ or call Member Services at 1-800-953-8854 for help.

Some specialty services do not need prior approval. We call this self‐referral. You can self‐refer to the following services:

• Emergency care
• Eye care exams
• Routine and preventive care from an OB/GYN
• Routine family planning services
• First visit with a physical therapist (you must get permission from MPC for follow-up visits)

Remember, except for family planning and emergency services, you must go to an MPC network provider. Otherwise, your service may not be covered.

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Primary Mental Health Services

Primary mental health services are basic mental health services provided by your PCP or another provider within MPC’s network.

Please Note: MPC does not cover specialty mental health services. If more than basic mental health services are needed, your PCP will refer you, or you can call the Public Behavioral Health System at 1-800-888-1965 for specialty mental health services.

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After‐Hours Care and Urgent Care

If you or your child gets sick after office hours or on the weekend, call your PCP’s office anyway. Your PCP’s office will have an answering machine telling you what to do. The PCP may have an answering service that will contact your PCP. The PCP will call you back to tell you what to do. If it is the middle of the night, give your PCP time to get back to you.

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MyVirtualMPC

MPC offers MyVirtualMPC, a free app that lets you skip the trip to the doctor’s office or clinic. Within seconds, you can send a secure chat message and share images or videos with a doctor. Doctors are available 24 hours, seven days a week. Visit https://www.marylandphysicianscare.com/members/virtual-doctor-visits/ for more information.

Emergency Care

If you are unsure it is an emergency, call your PCP. An emergency is the sudden onset of a medical condition with severe symptoms, including severe pain. These symptoms are so serious that you can see immediate medical care is urgent to prevent loss of limb or even life. A member who is pregnant and very ill may be in danger of losing her baby. Other emergency conditions may include:

• Bleeding that will not stop
• Difficulty breathing
• Seizures
• Broken bones
• Medicine or drug overdose
• Severe burns
• Chest pains
• Not able to move
• Suicide attempts
• Choking
• Passing out (blackouts)
• Throwing up blood
• Danger of losing limb or life
• Poisoning

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How to Get Emergency Care

Call 911 or go to the closest hospital if you are having an emergency. The hospital does not have to be in our network in this situation. You also do not need pre‐approval for emergency transportation to the hospital or emergency care.

Selecting a PCP and/or Changing a PCP

If you do not choose a PCP, MPC will select one. If you want a different PCP than the one assigned, the provider directory is available online at https://www.marylandphysicianscare.com/find-a-provider/. The online directory provides the name, address, phone number, specialty, board certification status, medical school background, and more information about the provider. If you do not have access to the internet or prefer a paper printout of the listing to be mailed to you, please call Member Services toll‐free at 1-800-953-8854.

New Technology for Medical Procedures

MPC always wants to make sure our members get safe, up‐to‐date, high‐quality medical care. A team of providers continually reviews new health care technologies and procedures and decides if they should become covered services.

While under investigation, new technologies and treatments are not covered services. Before covering new technologies, we will:

• Study the purpose of each technology
• Review medical literature
• Decide how the new technology may benefit members
• Develop guidelines on how and when to use the technology

Out‐of‐Service Care When Away from Home

There are times when you may be away from home, and you or your child needs care. MPC provides services in Maryland only. When you are out of our service area, routine care for you or your child is not covered. You are only covered for emergency services. If you are out of the service area and you or your child needs health care services, call your PCP, and they will tell you what to do. The PCP’s telephone number is on your MPC ID card. You can also call Member Services.

If you have an emergency while out of our service area, call 911 or go to the closest emergency room. Make sure you have your MPC ID card. If you or your child gets services in the emergency room and is admitted, have the hospital call our Member Services Department at 1-800-953-8854.

Member Complaints

We take member complaints and appeals very seriously. We want you to be happy with the services you receive from us. If you are not happy, please let us know. We want to know what is wrong so we can make our services better.

To file a complaint or appeal, visit https://www.marylandphysicianscare.com/member-complaints-grievances-and-appeals/ for more information.

If you want a Member Advocate to assist you in filing an appeal, contact MPC by phone or mail.

• Call Member Services at 1-800-953-8854
• Write and mail to:
  Maryland Physicians Care MCO
  Attn: Grievance and Appeals
  P.O. Box 893
  Portland, ME 04104

Tell us what happened. Give us as much information as you can. For example, include the date the incident happened, the names of the people involved and details about what happened. Be sure to include your name, child name, and member I.D. number.

You can get a second opinion at no cost to you. When a PCP or a specialist says you need surgery or other treatment, you can check with another provider. This is called a second opinion. Your PCP can recommend a provider, or you can call Member Services toll‐free at 1-800-953-8854.

Out‐of‐Network Services

MPC offers a wide network of providers and services. Occasionally, you or your child may need to go outside our network. Except for family planning and emergency care, all out‐of‐network services require pre‐approval. If approved, we will adequately and timely cover these services if we cannot provide the service within our network. If you have questions, please call Member Services toll‐free at 1-800-953-8854 or visit https://www.marylandphysicianscare.com/members/benefits/medical-coverage/.

Nondiscrimination Notice

MPC complies with applicable federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex. MPC does not exclude or treat people differently because of race, color, national origin, age, disability, or sex. View the full nondiscrimination notice at: https://www.marylandphysicianscare.com/wp-content/uploads/2020/11/nondiscrimination_noticeREV.pdf

Alternate Language and Format (TTD/TTY) Services

If you have a hard time seeing or hearing or do not speak or know English well, we can help. MPC offers language assistance services free of charge. Please call 1-800-953-8854 (TTY: 1-800-735-2258).

SPANISH/ESPAÑOL: Hay ayuda disponible en su idioma: 1-800-953-8854 (TTY: 1-800-735-2258). Estos servicios están disponibles gratis.

CHINESE/中文: 用您的语 言为您提供帮助: 1-800-953-8854 (TTY: 1-800-735-2258) 这些服 务都是免费的