Members

• The Enrollment Process
• Medical Assistance ACCESS Cards
• Determining Eligibility Through Gateway
• Primary Care Practitioner’s Role in Determining Eligibility
• Addition of Newborns
• Member Benefit Packages and Copayments
• Exception for Service Limits
• Benefits
  • Medical Benefits
  • Medical Assistance Benefits Package
  • Medical Assistance Categories
  • Covered Benefits
  • Audiology and Speech Therapy
  • Chiropractic/Podiatric Services
  • Dental
  • Durable Medical Equipment, Orthotics and Prosthetics
  • Dialysis
  • Family Planning
  • Home-Based Services
  • Hospice Services
  • Mental Health/Substance Abuse Services
  • Skilled Nursing Facility
  • Prescription Drug and Over-the-Counter Benefits
  • Drugs Covered Under the Full Benefit
  • Gateway Over-The-Counter Formulary
  • Medical Supplies
  • Rehabilitation
  • Vision
• Members’ Rights and Responsibilities

For more information or to request member outreach, please call Gateway’s Preventive Health Department at 1-800-642-3550, press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form.

The Enrollment Process

Gateway is offered to Medical Assistance recipients within Gateway’s service area. Gateway serves Medical Assistance recipients as a voluntary alternative to the traditional fee-for-service program and as an option in the HealthChoices mandatory program.

As of January 2005, the Department of Public Welfare employs a Pennsylvania Enrollment Services broker in the voluntary counties just like they do for the HealthChoices (mandated program) counties. An Enrollment Specialist explains the benefits offered by Gateway and other Physical Health Managed Care Organizations (PH-MCO) and helps the recipient choose a PH-MCO that meets their needs. Potential members are encouraged to select a primary care practitioner from a list of participating practitioners. The Pennsylvania Enrollment Services contractor electronically submits all applications to the Department of Public Welfare to validate. The Department of Public Welfare then electronically notifies the Pennsylvania Enrollment Services contractor and Gateway that a recipient will be enrolled in Gateway.

Medical Assistance recipients approved by the Department of Public Welfare from either the voluntary or HealthChoices programs are added to Gateway’s information system, with the effective date assigned by the Department of Public Welfare. It typically takes two (2) to six (6) weeks from the time a recipient calls the Pennsylvania Enrollment Services until they are enrolled with the PH-MCO. Newly enrolled members receive a new Member Handbook and a Gateway Identification Card. (see sample Gateway ID Card below)

Medical Assistance ACCESS Cards
The Department of Public Welfare issues a Pennsylvania ACCESS card to all eligible Medical Assistance recipients, including those recipients that choose to join Gateway. All Gateway members will have both a Department or Public Welfare ACCESS card and a Gateway identification card. If a patient presents an ACCESS card, the member’s eligibility can be verified through the Department of Public Welfare Eligibility Verification System (EVS). Practitioners must participate with the Medical Assistance Program in order to use the EVS.

To access the Department of Public Welfare EVS, call 1-800-766-5EVS (5387). Please have your 13-digit Master Provider Index (MPI) Number and the member’s State ID (also known as Recipient Number) from the member’s ACCESS card available when you call. Since important information is provided throughout the verification process, please listen to the entire message. If the recipient is covered by a managed care plan, such as Gateway, their eligibility with the plan is indicated immediately following the member’s demographic information (name, date of birth, etc.).

The Point of Service (POS) swipe-box provided by the Department of Public Welfare confirms all of the information provided through the EVS phone system, and provides printed verification for your records.

The following information is available from the EVS 1-800 number/POS device/PC Software:

Determining Eligibility Through Gateway

Because of frequent changes in a member’s eligibility, each participating practitioner is responsible for verifying a member’s eligibility with Gateway BEFORE providing services.  Verifying a member’s eligibility will ensure proper reimbursement for services.  To verify a member’s eligibility, the following actions are available to all practitioners:

1. Gateway Identification Card
   • The card itself does NOT guarantee that a person is currently enrolled in Gateway. Members are only issued an ID Card once upon enrollment, unless the member changes their primary care practitioner or requests a new card. Members are NOT required to return their identification cards when they are no longer eligible for Gateway.
   • The Gateway DIVA System (1-800-642-3515) is available 24 hours a day, seven days a week. To verify member eligibility at each visit, practitioners follow a few simple steps, which are listed below:

   TO BEGIN
   Press 1 if you are calling regarding a member that resides in Pennsylvania

   TO VERIFY MEMBER ELIGIBILITY

   Press 1 to verify eligibility

   Member Identification Number?

   Press 1 to verify eligibility using the patient’s social security number, when prompted enter the patient’s 9-digit social security number, then press the # key

   Press 2 to verify eligibility using the patient’s Gateway member identification number, when prompted enter the patient’s 8-digit Gateway identification number

   Press 3 to verify eligibility using the patient’s Medical Assistance recipient identification number, when prompted enter the patient’s Medical Assistance recipient identification number

   Press 4 to verify eligibility using the patient’s Medicare Health Insurance Claim (HIC) number, when prompted enter the patient’s HIC number, followed by the # sign. (For letters press the corresponding key on your touchtone phone. For example: To enter an A, B, or C, press the 2 key. For Q, press the 7 key. For Z, press the 9 key.)

   Press 0 to speak to a Provider Services Representative

   Press 9 to repeat the menu

   Verification of Date?

   Press 1 to verify whether the patient is eligible TODAY or the PCP assigned to the member
   Press 2 to verify whether the patient is eligible on a specific date. Enter the date using the 2-digit month, 2-digit day, and 4-digit year. Press 1 if the repeated date is correct.
   Press 2 if the repeated date is incorrect.
   Press 9 to listen to the instructions again
   Press 0 to speak to a Provider Services Representative

   Additional Instructions:

   Press 1 to receive additional information about the patient/member (includes the spelling of the member’s first and last name)
   Press 2 to receive the patient’s Primary Care Practitioner name and telephone number (includes the spelling of the provider’s name and telephone number)
   Press 3 to fax information regarding the patient whose eligibility is being verified
   

   • You will be asked to enter the fax number for which you wish to receive the eligibility verification. You will receive a fax that looks like one of the two samples below:
   • The above verification of eligibility fax receipts will either verify coverage for Benefit Plan 400 (Adult MA) or Plan 401 (Adult GA). Each disclaimer lists applicable benefits and copays for each Benefit Plan.
   Press 4 to verify eligibility for another patient/member
   Press 5 to exit
   Press 6 to return to the menu of automated services
   Press 9 to listen to the instructions again
   Press 0 to speak to a Provider Services Representative
   • ACCESS Cards
     • Showing a Medical Assistance ACCESS card does not indicate membership in Gateway.
     • Use the swipe-box or call EVS at 1-800-766-5EVS (5387) to verify a patient’s eligibility before providing services.

Primary Care Practitioner’s Role in Determining Eligibility

Primary care practitioners verify eligibility by consulting their panel listing in order to confirm that the member is a part of the practitioner’s panel. The panel list is distributed on or about the first of every month. The primary care practitioner should check the panel list each time a member is seen in the office. If a member’s name is on the panel list, the member is eligible with Gateway for that month.

If members insist they are effective, but do not appear on the panel list, the practitioner should call the Gateway Provider Services Department at 1-800-392-1145 for help in determining eligibility.

When a member selects Gateway, the member’s effective date is usually the first or the 15th of the month. However, when the member is a newborn, the member may be added at any time during the month. Because newborn information is reported to Gateway retroactively, newborns will show up as a retrospective addition to the primary care practitioner’s next monthly panel listing. Newborns will be effective on their date of birth or the date the newborn was added to the member’s grant.

Changes made in the Pennsylvania Medical Assistance program through the Governor’s 2005/2006 budget permitted Medicaid Managed Care Plans to implement the copayments and service limits in effect in the Medicaid FFS program. Gateway has implemented copayments and service limits for those members covered under the Adult General Assistance (Adult GA) and Adult Medical Assistance (Adult MA) benefit categories effective January 15, 2006.

Gateway members that are age 18 or older have copayments and some members age 21 or older have service limits and copayments. Copayments do not apply to members under 18 or any member who is pregnant (through the post-partum period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends) or in a nursing home. Members cannot be denied a service if they are unable to pay their copayment. Members are responsible up to a maximum of $90 for Adult MA and $180 for Adult GA every six months. Gateway will reimburse the member for any applicable co-pays based upon claims submission that exceed the maximum from January through June and again from July through December of each year.

The provider is required to submit in field 29 of the CMS-1500 form and field 54 of the UB-04 form the patient responsibility amount. Gateway's system automatically deducts the copayment from the provider's reimbursement and reflects this on the provider's Remittance Advice. Gateway tracks the applicable copayments on each claim and through a retrospective analysis will identify members that reach the thresholds and issue member reimbursements as necessary.

Exception for Service Limits

• The member has a serious chronic illness or other serious health condition and without the additional service their life would be in danger; or
• The member has a serious chronic illness or other serious health condition and without the additional service their health will get much worse; or
• The member would need more costly services if the exception is not granted; or
• The member would have to go into a nursing home or institution if the exception is not granted.
• Granting the exception is necessary in order to comply with state regulations.

Any exception request received prior to the service being rendered will get a response within 21 days of the date Gateway received the request. Prospective urgent exception requests will be responded to within 48 hours of the date and time Gateway received the request and requests received after the service has been rendered will be responded to within 30 days of the date that Gateway received the request.

A retrospective request for an exception must be submitted no later than sixty (60) days from the date Gateway rejects the claim because the service is over the benefit limit. Retrospective exception requests made after sixty (60) days from the claim rejection date will be denied.

Both the recipient and the provider will receive written notice of the approval or denial of the exception request. For prospective exception requests, if the provider or recipient is not notified of the decision within twenty-one (21) days of the date the request is received, the exception will be automatically granted.

Gateway denials of requests for exception are subject to the right of appeal by the Provider or recipient.

A provider may not hold a Gateway member liable for payment for services rendered in excess of the limits established unless the following conditions are met:

• The provider has requested an exception to the limit and Gateway denied the request.
• The provider informed the member before the service was rendered that the recipient is liable for payment if the exception is not granted.

Practitioners can verify a member’s medical assistance benefit category through the Department of Public Welfare PROMISe Eligibility Verification System (EVS). Once a member’s benefit category is verified, practitioners can use the reference table below to determine the applicable copayments and limits based on the members “Physical Health Benefit Package”.

*Copayments do not apply to members under 18 or any member who is pregnant (through the post-partum period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends) or in a nursing home. Members covered under the MA Adult benefit category do not have a copayment for the following kinds of drugs:

• Drugs, including immunizations, that you get in the doctor's office
• Anti-hypertensive agents
• Anti-diabetic agents
• Anti-convulsants
• Cardiovascular preparations
• Anti-psychotic agents, except those that are also schedule C-IV antianxiety agents
• Anti-neoplastic agents
• Anti-glaucoma drugs
• Anti-Parkinson drugs
• Drugs used only to treat HIV/AIDS>

The pharmacy will inform the member of any applicable copay for a prescription. Members cannot be denied a service if they are unable to pay their copay.

**The yearly limits will start again on July 1st of every year. Providers or members may request an exception to approve services above the yearly limits based on medical necessity.

Benefits

Medical Benefits

Gateway members are eligible for all the benefits covered under the Pennsylvania Medical Assistance Program. Members obtain most of their healthcare services either directly from or upon referral by their primary care practitioner, except for services available on a self-referral basis, such as family planning services, OB/GYN services, routine dental services, routine vision services, and mental health/substance abuse services. The primary care practitioner is responsible for the coordination of a member’s healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary providers, and other healthcare providers as needed.

The Department of Public Welfare has developed nine (9) Healthcare Benefit Packages. Each package was determined by dividing the recipient community into specific groups based on common eligibility characteristics. Under Medical Assistance, many benefits vary by the Healthcare Benefit Package of the recipient. A chart identifying the Gateway benefits, which vary by Medical Assistance Healthcare Benefit Package, follows:

Medial Assistance Categories

Covered Benefits

Covered benefits are NOT limited to the services that follow. Please contact Gateway’s Provider Services Department at 1-800-392-1145 with any questions regarding services not listed.

Audiology and Speech Therapy

Gateway members under the age of 21 are eligible to receive audiology services including hearing aids and ear molds.

Please refer to the Referrals and Authorizations Section of this Manual for additional information regarding Audiology and Speech Therapy.

Chiropractic/Podiatric Services

Members covered under the Adult MA and Adult GA benefit category are eligible for up to a combined 18 outpatient visits each year under a chiropractor or podiatrist. Providers are not responsible for tracking visits.

Please refer to the Referral and Authorization Section of this Manual for information regarding Chiropractic Services.

Dental

Dental care is provided at 100% of eligible Medical Assistance benefits for members under the age of 21. For members 21 and over, Gateway offers two benefit packages depending upon the member’s dental coverage with Medical Assistance. For members eligible for full dental benefits under Medical Assistance, Gateway provides all of the same benefits covered under the Medical Assistance Program. For those members who are eligible for only limited benefits under Medical Assistance, Gateway provides the same level of benefits as the Medical Assistance Program, as well as additional benefits for routine dental care and treatment, such as periodic oral exam, comprehensive oral evaluation, cleaning, bitewing x-rays, and panoramic x-ray.

Gateway contracts with United Concordia Companies, Inc. to provide covered dental services to members. Gateway’s Member Services Department is available to provide information regarding the participation status of individual practitioners.

The extraction of impacted wisdom teeth (bony or soft tissue impaction) is a covered dental benefit for Gateway members, and is covered through United Concordia Companies, Inc. All authorizations for the procedure and for any ancillary services must be obtained from the member’s dentist and United Concordia Companies, Inc. at 1-866-568-5467. Extraction of asymptomatic third molars is not a covered benefit.

Certain oral surgery procedures, which involve cutting the jaw, are covered as medical procedures through Gateway’s panel of oral surgery practitioners. A listing of Gateway participating Oral and Maxillofacial Surgeons is available via the On-line Provider Directory found at www.gatewayhealthplan.com. Members requiring these services must be referred by their primary care practitioner to a Gateway participating oral surgeon. The oral surgeon is responsible for authorizing surgical procedures performed in a hospital Short Procedure Unit (SPU) with Gateway prior to rendering services. Surgical services provided in the office are not subject to authorization procedures.

Even if the services the practitioner wishes to perform are not listed in this section, Gateway may cover them. Please contact Gateway’s Provider Services Department at 1-800-392-1145 to verify coverage of the specific service.

Durable Medical Equipment, Orthotics and Prosthetics

Refer to the Referral and Authorization Section of this Manual for additional information regarding Durable Medical Equipment, Orthotics and Prosthetics.

Dialysis

Coverage of Dialysis Services for Gateway members is limited by Medical Assistance to those members eligible for Medical Assistance under certain federally funded categories.

Family Planning

All family planning benefits provided under Gateway are administered by Adagio Health. If a Gateway member presents for family planning benefits, please be aware of the following:

• The member’s Gateway eligibility can be verified by calling 1-800-642-3515.
• Family planning patients DO NOT need a referral from their primary care practitioner under federal mandate. If a member becomes pregnant, she may self-refer to her OB/GYN for prenatal care. The Department of Public Welfare permits members to see any participating or non-participating practitioner for family planning services.
• The Sterilization Consent Form (MA-31), found in the Forms and Reference Materials Section of this manual, must be obtained from the patient thirty (30) days prior to the procedure.
• The appropriate documentation must be obtained for abortion services.
• Family planning procedures MUST BE PRE-AUTHORIZED at least five (5) working days prior to the procedure by calling Adagio Health at 1-800-532-9465.

Items to note include:

• Post-partum tubal ligations MUST BE PRE-AUTHORIZED by Adagio Health.
• All outpatient laboratory testing should be ordered with a prescription through the member’s primary care practitioner or OB/GYN according to the primary care practitioner’s designated laboratory.
• Reversals of tubal ligations, vasectomies and infertility treatments ARE NOT COVERED by the Pennsylvania Medical Assistance Program or Gateway.

Pregnancy termination coverage follows that established by the Department of Public Welfare. Only those cases that are related to rape, incest or endangerment to the life of the mother are covered. A provider must complete the appropriate Department of Public Welfare physician certification forms, i.e. MA-3, MA-368 or MA-369 and submit the completed form to Adagio Health. Adagio Health will issue an approval for payment once the appropriate forms are received and reviewed. Adagio Health may be contacted at 1-800-532-9465. The appropriate forms may be faxed to 412-201-4701.

Home-Based Services

Private Duty Nursing services, when medically necessary, are covered for Gateway members under the age of 21. Gateway members 21 and over are not eligible to receive private duty nursing services through Gateway.

Gateway’s Care Management Department coordinates medically necessary private duty nursing services with the ordering practitioner and the home healthcare provider. The Care Management Department can be reached at 1-800-642-3550, option 1.

Please note: Gateway cannot accept bills in half-hour increments. Providers must bill in whole hours.

Hospice Services

Should a member be in need of hospice care, the primary care practitioner, attending physician, hospital Utilization Review Department, or hospice agency should contact Gateway’s Utilization Management Department. Gateway will coordinate the necessary arrangements between the primary care practitioner and the hospice provider in order to ensure continuity of the member’s care.

To obtain authorization please call Gateway’s Utilization Management Department at 1-800-392-1146.

Mental Health/Substance Abuse Services

Mental Health and Substance Abuse Services are available to Gateway members on a self-referral basis. Access to these services is administered to members depending on where the member resides. Please refer to the Quick Reference Section of this Manual for the appropriate telephone numbers.

Skilled Nursing Facility

Refer to the Referral and Authorization Section of this Manual for additional information regarding Skilled Nursing Facilities.

It should be noted, per Gateway’s agreement with the Department of Public Welfare, that Gateway will be financially responsible for thirty (30) days of nursing coverage. On the thirty-first (31st) day, the ordering practitioner should begin billing the Medical Assistance Program since the member will be disenrolled from Gateway.

Prescription Drug and Over-the-Counter Benefits

Select over-the-counter (OTC) pharmaceuticals including vitamins are a covered benefit for all members. Members must have a written prescription for each OTC pharmaceutical/vitamin, and the prescription must be filled by a Gateway participating pharmacy.

Full prescription drug benefits are available to those members who are under 21 years of age. For members age 21 and over there are two pharmacy benefit packages that are based on the member’s category of Medical Assistance eligibility.

Prescriptions must be filled by a Gateway participating pharmacy in order to be covered by Gateway. When a member travels outside of the Gateway service area and must access a non-participating pharmacy, the member should utilize any Argus contracted Pharmacy and the claims should be billed to Gateway via the Argus Network.

Copayments are applicable for prescriptions for members age 18 or older who are not pregnant (excluding the post-partum period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends) or in a nursing home. Please refer to the Member Benefit Packages and Copayments section of this manual for additional information regarding copayments.

Gateway contracts with Argus to develop a network of chain and independent pharmacies in order to provide pharmaceuticals to Gateway members. A list of participating pharmacies can be obtained by contacting Gateway’s Member Services Department at 1-800-392-1147. Gateway also contracts with specialty pharmacy providers who are equipped to supply injectable medications to meet the unique needs of its participating Gateway providers and members. Medications that may only be dispensed by a participating specialty pharmacy are noted in the Gateway formulary book by the SPN notation.

Gateway utilizes a closed formulary. Practitioners are requested to prescribe medications included in the formulary whenever possible. Gateway's formulary is updated on a regular basis and can be accessed online at www.gatewayhealthplan.com. Medication additions or deletions reflect the decisions made by Gateway's Pharmacy and Therapeutics Committee. If a formulary deletion is made that affects one of your patients, Gateway will provide you with notification within 30 days prior to the change. Additional copies of the formulary may be printed directly from our formulary website or requested through Provider Services by calling 1-800-392-1145.

Some medications, although listed on the formulary, require prior authorization to be covered. All prior authorization and step therapy criteria can be found on Gateway's website. If use of a formulary medication is not medically advisable for a member, you must initiate a Request for Non-Formulary Drug Coverage. Please refer to the Forms and Reference Materials Section of this manual for a copy of this form. Please refer to the Referral and Authorization section of this manual for information regarding requesting non-formulary drugs. The exceptions process allows for a one business day turnaround when reviewing requests for non-formulary, prior authorization, and step therapy medications.

Gateway is dedicated to providing our physicians with access to the most up-to-date medication safety information. Drug recall and drug safety updates can occur on a daily basis due to newly published research or to the Food and Drug Administration’s (FDA) Adverse Event Reporting Program. In order to provide you with the latest information, Gateway has posted links to the FDA website to relate to providers the latest recalls and drug safety alerts that may affect their patients.

Drugs Covered Under the Full Benefit

• Legend drugs listed in the closed formulary
• Non-formulary drugs which have been granted a formulary exception for an individual member
• Non-legend drugs listed in the Gateway Over-The-Counter Formulary Section
• Insulin/disposable syringes/needles
• Disposable urine/blood glucose/acetone testing agents
• Compounded medication of which at least one ingredient is an FDA-approved prescription drug included on the formulary or granted a formulary exception
• Contraceptives

The limit is an amount normally prescribed by the practitioner, but must not exceed a 34-day supply. Prescriptions can be refilled up to 12 months from the original prescription date as authorized by the practitioner.

Exclusions (Applicable regardless of category of Medical Assistance Health Benefits package):

• Non-legend drugs other than those specifically listed in the Over-The-Counter Formulary below
• DESI Drugs: less than effective drugs as defined by the Federal Drug Administration
• Non-rebated Manufacturers (Gateway excludes coverage for any drug marketed by a drug company who does not participate in the Medicaid Drug Rebate Program)
• Impregnated gauze (and similar or related products)
• Non-legend soaps, cleaning agents, dentifices, mouthwashes, douche solutions, diluents, ear wax removal agents, deodorants, linaments, antiseptics, irrigants, emollients, and other personal care and medicine chest items
• Non-legend aqueous saline solutions for any use other than intravenous administrations
• Non-legend water preparations such as distilled water, water for injections, and identical, similar or included products
• Non-legend cough-cold preparations for MA recipients over 21 years of age
• Minoxidil (Rogaine) for the treatment of alopecia
• Drugs prescribed for cosmetic purposes
• Therapeutic devices or appliances, including needles, syringes, support garments and other medicinal substances, regardless of intended use, except those listed above
• Charges for administration or injection of any drug
• Prescriptions which an eligible person is entitled to receive without charge from any Worker’s Compensation Claim
• Drugs prescribed for investigational or experimental purposes
• Biologicals, blood or blood plasma
• Non-legend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes, and similar items
• Non-legend food supplements
• Any prescription refilled in excess of the number specified by the practitioner
• Anorexients
• Fertility Drugs
• Drugs prescribed for the treatment of erectile dysfunction

For coverage, drugs must be written as a prescription. Drugs are listed alphabetically by category with their corresponding formulary chapter noted. Specific OTC drugs are listed as examples and are not inclusive of all covered products.

Medical Supplies

Please contact Gateway’s Provider Servicing Department for information regarding Medical Supplies.

Rehabilitation

Refer to the Referral and Authorization Section of this Manual for additional information regarding Rehabilitation.

Vision

Gateway members have coverage for eye examinations. Gateway has subcontracted with Davis Vision to administer its routine vision benefits, providing Gateway members with access to the largest number of vision care practitioners possible. Gateway’s Member Services Department is available to provide information regarding the participation status of individual practitioners.

All Gateway members have coverage for eye examinations and/or contact lens fittings. Members age 21 and under can receive additional medically necessary eye examinations.

Members under the age of 21 are eligible for two basic pairs of glasses and one pair of contact lenses per calendar year. Replacement pairs are covered if medically necessary or if under warranty. Members 21 years of age and older are eligible for one basic pair of glasses or one pair of contact lenses per calendar year.

For all members, cosmetic tinted contacts are excluded.

If a member chooses frames or specialty contact lenses costing more than Gateway allows, the member may be charged an additional fee.

Gateway members may self-refer to any Davis Vision participating vision care practitioner for a routine refractive eye exam, eyeglasses, and contacts if medically necessary. The primary care practitioner does not need to issue a Gateway referral.

Should the member require additional medical services, the member will need a referral from the primary care practitioner to a Gateway participating ophthalmologist or a Davis Vision optometrist. When referring to an optometrist for non-routine services a referral form is required.

Requests for services outside the vision benefit plan must be submitted to Gateway’s Utilization Management Department for review via the Gateway Contracting Department.

All Gateway members have rights and responsibilities.  They are as follows:

GATEWAY HEALTH PLAN^® MEMBERS’ RIGHTS AND RESPONSIBILITIES STATEMENT

Member Rights

As a Gateway Member, you have the right to:

1. Get information about Gateway, the services Gateway provides, doctors and other healthcare 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 provider 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 choices for your condition with a doctor or other healthcare provider, including treatment options, risks of treatments, 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 race, color, religion, sex, age, disability, national origin, or without regard to whether you have an advance directive.
6. Pick your own doctor from Gateway’s network of doctors.
7. Refuse care from certain doctors.
8. File a complaint or grievance about Gateway or the care it provides.
9. Make recommendations regarding Gateway’s members’ rights and responsibilities policies.
10. Request a fair hearing from the Department of Public Welfare.
11. Prepare a Living Will and/or Advance Directive.
12. 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.
13. Have your medical records kept private and confidential.

Member Responsibilities

As a Gateway 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.

Si desea recibir una copia de esta información en español, por favor llame al numero 1-800-392-1147.