Administrative Policies and Procedures

• Adding New Members to Gateway
• When You Move
• Other Insurance
• 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

When you have a new baby or add a new member to your family, you should call Member Services at 1-800-392-1147 (TTY/TDD 711). A newborn will automatically be added to the mother’s health plan at the time of birth. It is also important to let your caseworker at the County Assistance Office know about your baby’s birth. If you don’t tell Gateway and your caseworker, your new family member’s Gateway insurance may be delayed.

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If you move, it is very important to tell your caseworker at the County Assistance Office. Gateway can only update your address and phone number after your caseworker updates your Department of Public Welfare file. Your new address and phone number are needed so that Gateway can send you information about your health plan. If you move out of the counties that Gateway services, you cannot keep your Gateway coverage. Call Member Services at 1-800-392-1147 (TTY/TDD 711) to let Gateway know you moved.

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You or one of your family members might have other types of insurance. Call Member Services at 1-800-392-1147 (TTY/TDD 711) if you or any member of your family is covered by Gateway and another insurance plan. Your caseworker at the County Assistance office also needs to know this information. If you have health, dental or vision insurance through another insurance company, you must use that insurance coverage first as a primary insurance. Gateway is always the last payer to other insurance coverage you may have. It is important to show your healthcare providers all of your insurance cards.

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Pennsylvania Medical Assistance providers cannot charge you for services that are covered by Gateway. If you get a bill from your doctor or the hospital by mistake, do not pay the bill. Please call Member Services at 1-800-392-1147 (TTY/TDD 711) with the billing information and a representative will help you.

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Gateway will let you know if there are changes in your benefits or the way you receive your services. An example of a change would be if your Primary Care Physician (PCP) or specialist were no longer part of Gateway’s list of participating doctors, called the “network”. Member Services will call you or send a letter to give you a chance to pick a new doctor, so there will not be a problem or delay for you to get the care you need. It is important to note that changes in your medical assistance benefit package or general eligibility status are made by the County Assistance Office.

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If you would like to enroll with Gateway or change your health plan from Gateway to another plan at any time, call Pennsylvania Enrollment Services at 1-800-440-3989 (TTY/TDD 1-800-618-4225) or enroll online at www.enrollnow.net.

Pennsylvania Enrollment Services is responsible for enrollment activities. Pennsylvania Enrollment Services employs trained, professional staff called Enrollment Specialists (ES). The ES’s primary responsibility is to enroll MA consumers into the plan that best meets their needs. The ES assists consumers by providing objective information so they can choose a physical health plan for their medical needs and a Primary Care Physician (PCP) to manage their care.

Other responsibilities of Pennsylvania Enrollment Services include, but are not limited, to the following:

• Provide education and information to MA consumers to enable them to make informed choices of a physical health plan
• Enroll MA consumers in the physical health plan of their choice
• Assist with the selection of a Primary Care Physician(PCP)
• Provide information about Behavioral Health Services and how to access those services

If you are hearing impaired and use a TTY/TDD (Telecommunication Device for the Deaf) service, you can call toll-free number, 1-800-618-4225 to enroll with Gateway or change your health plan from Gateway to another plan.

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You will stay a member of Gateway Health Plan^® unless:

• You want to change health plans
• You move from a HealthChoices to a non-HealthChoices county
• You move outside of Gateway’s service area
• The Pennsylvania Department of Public Welfare closes your case

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An “involuntary disenrollment” is when your Gateway membership ends without you asking for the change. Your Gateway membership will end if your case is “closed” by the Pennsylvania Department of Public Welfare.

If your case is “closed” for less than 6 months and then opens up again, you will automatically be put back on Gateway.

If your case is “closed” for more than 6 months and then opens up again, the Pennsylvania Department of Public Welfare will not put you back on Gateway Health Plan^® automatically.

• If you want to become a Gateway member again, you must call Pennsylvania Enrollment Services 1-800-440-3989(TTY/TDD 1-800-618-4225) or enroll online at www.enrollnow.net.

If you do not contact Pennsylvania Enrollment Services to choose a plan, the Pennsylvania Department of Public Welfare will automatically choose a plan for you.

It will take 4-6 weeks for your new membership to start.

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Rights and Responsibilities

Member Rights

As a Gateway Health Plan^® Member, you have the right to:

1. Get information about Gateway, the services Gateway provides, doctors and other health care providers giving you care, and your rights and responsibilities as a Gateway member.
2. Be treated with respect and recognition of dignity and right for privacy when receiving healthcare.
3. Work with your doctor or other healthcare providers in making decisions about your healthcare and to express preferences about future treatment decisions.
4. Openly discuss, without any limitations by Gateway, appropriate or medically necessary treatment choice for your condition with a doctor or other healthcare provider, including treatment options, risks of treatment, alternative therapies and consultations or tests that may be self administered, regardless of the cost or if it is a benefit.
5. Receive your medical and nursing care without regard to marital status, race, color, religion, sex, sexual preference, handicap, age, national origin, whether you have an advance directive or any other bias prohibited by law.
6. Remain free from seclusion used as a means of coercion, discipline, convenience or retaliation.
7. Pick your own doctor from Gateway’s network of doctors.
8. Refuse care from certain doctors.
9. File a complaint or grievance about Gateway or the care it provides.
10. Make recommendations regarding Gateway’s members’ rights and responsibilities policies.
11. Request a fair hearing from the Department of Public Welfare.
12. Prepare a Living Will and/or an Advance Directive.
13. See, or have your medical record copied, within Federal and State laws, and to request that your medical record be changed or corrected within Federal laws.
14. Have your medical records kept private and confidential.

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As a Gateway Health Plan^® member, you have a responsibility to:

1. Give information to your doctor, other healthcare provider, or Gateway so they can provide care to you.
2. Follow the instructions and treatment plans that you agreed on with your doctor or other healthcare provider.
3. Provide consent to healthcare providers and Gateway to help them manage your care, to improve your health or for research.
4. Understand your health problems. As much as you can, take part in making a plan for treatment goals with your doctor or other healthcare providers.
5. See the doctor you picked on a regular basis.
6. Treat the people giving you medical care with the same respect and kindness you expect for yourself.

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