Scott & White Health Plan

New Enrollee Information

About Scott & White Health Plan

Managed Care is a system of health care delivery that tries to improve the quality of health care while controlling the cost of health care. A mechanism of achieving this goal is through a Health Maintenance Organization (HMO), an entity that provides coverage for designated health services needed by plan members for a fixed, prepaid premium. Scott & White Health Plan (SWHP) is a group/network model. Because SWHP is an HMO, you can expect the following:

• To choose a primary care physician (PCP) from a panel of contracted or salaried providers who will provide and coordinate your care
• To allow your PCP to coordinate all of your health care needs, including referrals to specialists for subspecialty care and requests for certain tests and procedures
• To enjoy your membership in one of the finest health care delivery systems available in Texas

Please review this handbook for a summary of what to expect with your SWHP membership. This summary is not a contract. For detailed information about your benefits, please refer to your Health Care Evidence of Coverage.

Enrollee Rights And Responsibilities

Rights

1. You have the right to be provided with information about SWHP, its services, and the providers and practitioners giving you care.
2. You have the right to receive information regarding your enrollee rights and responsibilities.
3. You have the right to be treated with respect and recognition of your dignity and right to privacy.
4. You have the right to participate in decision-making regarding your health care.
5. You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
6. You have the right to voice complaints, appeals or grievances about your coverage through SWHP or the care provided by SWHP providers in accordance with your health care agreement.
7. You have the right to make recommendations regarding SWHP's enrollee rights and responsibilities policies.
8. You have the right to have an advance directive, such as a Living Will or Durable Power of Attorney for Health Care Directive. These documents express your choices about your future care or name someone to decide if you cannot speak for yourself.
9. You have the right to expect that medical information is kept confidential in accordance with your health care agreement.

Responsibilities

1. It is your responsibility to choose a PCP and to notify SWHP Customer Service of any change in PCP selection.
2. It is your responsibility to notify SWHP regarding any out-of-plan care.
3. It is your responsibility to follow SWHP instructions and rules and abide by the terms of your health care agreement.
4. It is your responsibility to provide information (to the extent possible) the organization and its practitioners and providers need in order to provide care.
5. It is your responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
6. It is your responsibility to follow plans and instructions, to the best of your ability, for care you have agreed on with your practitioner(s) and provider(s).
7. It is your responsibility to give SWHP providers a copy of an advance directive, if one exists.

8. It is your responsibility to advise SWHP or SWHP providers of any dissatisfaction you may have in regard to your care while a patient, and to allow the opportunity for intervention to alter the outcome whenever possible.

Your Privacy Is Very Important To Us

As a trusted name in health care, Scott & White Health Plan knows the importance of keeping your protected health information (PHI) private and confidential. PHI includes medical and any individually identifiable information; for example, your name, social security number or address. Scott & White Health Plan protects your PHI by:

• Limiting who can see your PHI
• Limiting how your PHI is used and disclosed
• Setting and strictly adhering to Scott & White Health Plan privacy policies

Scott & White Health Plan uses and discloses your PHI without your written consent to conduct the following functions:

• Treatment - includes sharing information with providers involved in your care in order for you to receive medical treatment
• Payment - to pay claims for covered services to providers
• Other health care operations - for quality improvement purposes, including medical research, developing clinical guidelines, case management, medical review, legal services/ litigation, detection of fraud and abuse, as well as audit functions (in accordance with applicable law)

Scott & White Health Plan has recently revised its Notice of Privacy Practices. For more information, please contact your local SWHP office.

Notice of Mandatory Benefits

This notice is to advise you of certain coverage and/or benefits provided by your contract with SWHP.

Mastectomy or Lymph Node Dissection

Minimum Inpatient Stay: If due to treatment of breast cancer, any person covered by this plan has either a mastectomy or a lymph node dissection, this plan will provide coverage for inpatient care for a minimum of:

• 48 hours following a mastectomy
• 24 hours following a lymph node dissection

The minimum number of inpatient hours is not required if the covered person receiving the treatment and the attending physician determine that a shorter period of inpatient care is appropriate.

Prohibitions: We may not (a) deny any covered person eligibility or continued eligibility or fail to renew this plan solely to avoid providing the minimum inpatient hours; (b) provide money payments or rebates to encourage any covered person to accept less than the minimum inpatient hours; (c) reduce or limit the amount paid to the attending physician, or otherwise penalize the physician, because the physician required a covered person to receive the minimum inpatient hours; or (d) provide financial or other incentives to the attending physician to encourage the physician to provide care that is less than the minimum hours.

Coverage and/or Benefits for Reconstructive Surgery After Mastectomy

Coverage and/or benefits are provided to each covered person for reconstructive surgery after mastectomy, including:

• All stages of the reconstruction of the breast on which mastectomy has been performed
• Surgery and reconstruction of the other breast to achieve a symmetrical appearance
• Prostheses and treatment of physical complications, including lymphedemas, at all stages of mastectomy

The coverage and/or benefits must be provided in a manner determined to be appropriate in consultation with the covered person and the attending physician.

Prohibitions: We may not (a) offer the covered person a financial incentive to forego breast reconstruction or waive the coverage and/or benefits shown above; (b) condition, limit, or deny any covered person's eligibility or continued eligibility to enroll in the plan or fail to renew this plan solely to avoid providing the coverage and/or benefits shown above; or (c) reduce or limit the amount paid to the physician or provider, nor otherwise penalize, or provide a financial incentive to induce the physician or provider to provide care to a covered person in a manner inconsistent with the coverage and/or benefits shown above.

Examinations for Detection of Prostate Cancer

Benefits are provided for each covered male for an annual medically recognized diagnostic examination for the detection of prostate cancer. Benefits include:

• A physical examination for the detection of prostate cancer
• A prostate-specific antigen test for each covered male who is at least 50 years of age
• At least 40 years of age with a family history of prostate cancer or other prostate cancer risk factor

Inpatient Stay Following Birth of a Child

For each person covered for maternity/childbirth benefits, we will provide inpatient care for the mother and her newborn child in a health care facility for a minimum of:

• 48 hours following an uncomplicated vaginal delivery
• 96 hours following an uncomplicated delivery by cesarean section

This benefit does not require a covered female who is eligible for maternity/childbirth benefits to (a) give birth in a hospital or other health care facility or (b) remain in a hospital or other health care facility for the minimum number of hours following birth of the child.

If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for post delivery care. Post delivery care includes parent education, assistance and training in breast-feeding and bottle-feeding and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse or other appropriate licensed health care provider, and the mother will have the option of receiving the care at her home, the health care provider's office or a health care facility.

Prohibitions: We may not (a) modify the terms of this coverage based on any covered person requesting less than the minimum coverage required; (b) offer the mother financial incentives or other compensation for waiver of the minimum number of hours required; (c) refuse to accept a physician's recommendation for a specified period of inpatient care made in consultation with the mother if the period recommended by the physician does not exceed guidelines for prenatal care developed by nationally recognized professional associations of obstetricians and gynecologists or pediatricians; (d) reduce payments or reimbursements below the usual and customary rate; or (e) penalize a physician for recommending inpatient care for the mother and/or the newborn child.

Coverage for Tests for Detection of Colorectal Cancer

Benefits are provided, for each person enrolled in the plan who is 50 years of age or older and at normal risk for developing colon cancer, for expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer. Benefits include the covered person's choice of:

• A fecal occult blood test performed annually and a flexible sigmoidoscopy performed every five years
• A colonoscopy performed every 10 years

Coverage of Tests for Detection of Human Papillomavirus and Cervical Cancer

Coverage is provided, for each woman enrolled in the plan who is 18 years of age or older, for expenses incurred for an annual medically recognized diagnostic examination for the early detection of cervical cancer. Coverage required under this section includes at a minimum a conventional Pap smear screening or a screening using liquid-based cytology methods, as approved by the United States Food and Drug Administration, alone or in combination with a test approved by the United States Food and Drug Administration for the detection of the human papillomavirus.

If any person covered by this plan has questions concerning the mandatory benefits, please call SWHP at (800) 321-7947, or write us at 2401 S. 31st Street, Temple, TX 76508.