Medicaid Member Handbook

Member Handbook Download (PDF)

Manual Para Miembros (PDF)

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.

Table Of Contents

• Member Services
• Gateway Health Plan^® Notice of Privacy Practices
• Hearing and Sight Problems
• Non-English Speaking Members
• Gateway Health Plan^® ID Card

• Primary Care Physician (PCP)
• How Can I Change My Doctor?
• Specialty Care Referral
• When Do You Not Need a Referral?
• How Can I Get a Second Opinion?
• Arranging Your Care
• Out of Network Care
• Other Medical Staff in Your Doctor's Office
• More Information About Your Doctor
• Hospital Care
• Emergency Services
• When Out of Town
• Transportation for Medical Services

• Covered Benefits
• Benefit Limits
• Benefit Limit Exceptions
• Medicines
• Can the Formulary Change?
• Utilization Management
• Eye Exams and Eyeglasses
• Dental Care
• Special Needs
• Mental Health, Drug and Alcohol Services
• AIR Gateway^® Asthma Program
• Help Your Heart Cardiac Program
• Healthy Returns Diabetes Program
• MOM Matters^® Program
• Women, Infants and Children (WIC) Program
• Growing Up with Gateway^SM Program
• Early Intervention Services
• Family Planning
• HIV/AIDS Services
• Chiropractic Services
• Services Not Covered

• Adding New Members to Gateway
• When You Move
• Other Insurance
  • If You Have Medicare Benefits
• Claims-What Do I Do With a Bill?
• Changes in Benefits or Services
• Changing Health Plans
  • When You Stop Being a Gateway Member
• Involuntary Disenrollment
• Rights and Responsibilities
  • Member Rights
  • Member Responsibilities

• COMPLAINTS
  • What is a complaint?
  • What should I do if I have a complaint?
  • First Level Complaint
  • What if I don't like Gateway’s decision?
  • Second Level Complaint
  • What happens after I file a second level complaint?
  • External Complaint Review
• GRIEVANCES
  • What is a grievance?
  • What should I do if I have a grievance?
  • What if I don't like Gateway’s decision?
  • Second Level Grievance
  • What can I do if I still don’t like Gateway’s decision?
  • External Grievance Review
  • What can I do if my health is at immediate risk?
• Persons with Disabilities
• DEPARTMENT OF PUBLIC WELFARE FAIR HEARINGS
  • What happens after I ask for a fair hearing?
  • What can I do if my health is at immediate risk?
• Advance Directives
• HealthChoices Clinical Sentinel Hotline
• Suggestions for Changes
• Fraud and Abuse
• New Technology: Is it Covered?
• Other Information
• Eligibility
• Important Notice
• Important Phone Numbers for Mental Health, Drug, & Alcohol Services
• Medical Assistance Transportation