For Members of HIP VIP^®Medicare Plan

For Parents of Child Health Plus Members

For Medicaid and Family Health Plus Members

For Members of HIP Prime^®,HIP HMO and HIP HMO Direct

For Members of HIP Prime^®POS, HIP Choice Plus and HIP Choice Plus Direct

For Members of HIP VIP^®Medicare Plan

For Members of HIPaccess I and HIPaccess II

What is the New Member ID/NMI?

1. What's the role of my Primary Care Physician?

Your Primary Care Physician (PCP) is your personal physician. He or she provides your health care and/or refers you to specialists when you need specialty services. It's very important for you to understand that neither HIP nor Medicare will cover care you receive without a referral from your PCP. There are a few exceptions, which are referred to in the answer to Question 4 below.

Look on your HIP Identification Card. Your PCP's name and phone number are printed on the front of the card. If the name that appears is not the PCP you selected, or if no name appears, call HIP Customer Service at 1-800-HIP-TALK [1-800-447-8255 (TDD: 1-888-447-4833)]. To see the latest list of participating providers, you can use HIP's online Provider Search feature.

2. Do I call my PCP in an emergency?

Yes, unless it's a life-threatening emergency. In a life-threatening emergency, you should call 911 and get the help you need immediately. Keep in mind that your plan does not cover use of hospital emergency rooms for non-emergency care, that is, for care that does not match the definition of "life-threatening emergency" in the answer to Question 3 below. In these non-emergency situations, call your PCP for the help you need.

3. What constitutes an "emergency"?

An emergency condition is a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy.
• Serious impairment to such person's bodily functions.
• Serious dysfunction of any bodily organ or part of such person.
• Serious disfigurement of such person.

4. What happens if I go to see a specialist without a referral from my PCP?

In most cases, going directly to a specialist without a referral is not covered. However, there are a few exceptions. For example, you may schedule an appointment with any of the following specialists who participate in the network, without first visiting and obtaining a referral from your PCP: *

• Chiropractor
• Nutritionist
• Optometrist
• Social Worker
• Mental Health Provider
• Women's health care specialist (OB/GYN)
• Podiatrist (for routine care)
• In addition, female members do not need a referral to access their annual screening mammography benefit.

Don't hesitate to ask your PCP about certain specialists if you think that is important. Often, though, it's a good idea to accept your PCP's judgment about referrals. Most primary care doctors - whether they participate in a health plan like HIP or not - prefer to give referrals to specialists they work with regularly. That means your PCP will refer you to specialists that he or she knows and trusts. It also assures coordination of your care when you need to see more than one doctor.

No, you do not have to obtain prior approval from HIP before getting care. However, we'd like to take this opportunity to remind you that the primary responsibility for your care is in the hands of your PCP. If you receive care from your PCP, or through referral from your PCP, the PCP will get any necessary approvals for you. (Sometimes, if you. ve already been referred to a specialist, the specialist may secure the approval instead.) Only certain services require prior approval:

• Non-emergent transportation (i.e., land and air ambulances).
• All inpatient hospital admissions (non-emergency).
• Ambulatory surgery (in a hospital setting or in a freestanding surgery center).
• Skilled nursing facility admissions.
• Rehabilitation care (inpatient).
• Inpatient behavioral health, alcohol or substance abuse treatment.
• Home health care (nursing, physical therapy, occupational therapy, speech therapy and infusion therapy).
• Durable medical equipment (customized and rental).
• All non-emergent or non-urgent services provided by any non-participating medical provider or facility, except out-of-area renal dialysis services.
• Transplant evaluation and services.

Even though your PCP will handle the request for prior approval, it's a good idea to check with your PCP's office staff in these cases to be sure that advance approval was obtained. (It's also a good idea to call the office of the doctor you've been referred to for confirmation that he or she still participates in the HIP network.)

7. How long should it usually take to get an appointment with a HIP participating physician?

We realize that when you decide to see a doctor, you would like an appointment right away. In emergencies or urgent situations you can get appointments immediately or within 24 hours as needed. Because all doctors' offices have to set priorities by level of urgency, please be patient when it takes a little longer to get an appointment for more routine care. And please try to call well in advance to schedule your annual complete physical exam, which requires a longer appointment than usual.

Please also understand that your doctor may not be ready to see you exactly on time. Emergencies and urgent situations arise frequently for physicians, and even the best-planned schedules can be unavoidably disrupted as a result.

8. If I have more questions, where do I go for help?

If you have a question or concern about your HIP membership, you can contact Customer Service via e-mail and expect a response within 48 hours. Another convenient source of information is HIP's automated Interactive Voice Response (IVR) system. Just call 1-800-HIP-TALK (1-800-447-8255) any time of the day or night to order HIP forms and directories, verify your eligibility or request a new member ID Card. Or, if you prefer the option of speaking with a Customer Service Advocate, these experts are available Monday through Friday, 8 am to 6 pm at
1-800-HIP-TALK (1-800-447-8255).

If you have a hearing or speech impairment and use a TDD, please call
1-888-HIP-4TDD (1-888-447-4833) Monday - Friday, 8:30 am - 5 pm.

Important Note: HIP has arranged for certain administrative functions to be handled by provider organizations. As a result, you may have some different contact points. Check the back of your HIP ID Card for any special contact information. If the Card differs from the phone numbers given above, follow the instructions on your Card instead.

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