Member Handbook 1

New Hampshire
Medicaid Care
Management Program
Member Handbook
Effective January 1, 2019

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 2

Table of Contents

Chapter 1. Getting started as a member ........................................................ 5

Section 1.1 Welcome ..........................................................................................5
Section 1.2 What makes you eligible to be a plan member ................................5
Section 1.3 What to expect from the plan ...........................................................6
Section 1.4 Staying up-to-date with your personal information and
other insurance information .............................................................8
Section 1.5 How other insurance works with our plan .......................................9

Chapter 2. Important phone numbers and resources ................................ 10

Section 2.1 How to contact NH Healthy Families Member Services ...............10
Section 2.2 How to contact the plan about a coverage decision or to file
an appeal ........................................................................................11
Section 2.3 How to contact the plan about a grievance ....................................12
Section 2.4 How to contact the plan about care coordination...........................13
Section 2.5 How to contact the plan’s Nurse Advice Line ...............................14
Section 2.6 How to request behavioral health services (mental health or
substance use disorder services) ....................................................15
Section 2.7 How to request non-emergency medical transportation ................16
Section 2.8 How to contact the NH DHHS Customer Service Center .............18
Section 2.9 How to contact the NH Long-Term Care Ombudsman .................19
Section 2.10 How to contact the NH DHHS Ombudsman .................................20
Section 2.11 How to contact ServiceLink Aging & Disability Resource
Center .............................................................................................21
Section 2.12 How to report suspected cases of fraud, waste or abuse ...............22
Section 2.13 Other important information ..........................................................24

Chapter 3. Using NH Healthy Families for covered services ..................... 26

Section 3.1 Your Primary Care Provider (PCP) provides and oversees
your medical care ...........................................................................28
Section 3.2 Services you can get without getting approval in advance ...........30
Section 3.3 How to get care from specialists and other network
providers ........................................................................................30
Section 3.4 What happens when a PCP, specialist or another network
provider leaves our plan .................................................................33
Section 3.5 Getting care from out-of-network providers ..................................34
Section 3.6 Emergency, urgent, and after-hours care .......................................35
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 3

Chapter 4. Covered services ........................................................................ 40

Section 4.1 About the Benefits Chart (what is covered) ...................................40
Section 4.2 Benefits Chart ................................................................................41
Section 4.3 Extra or supplemental benefits provided by the plan.....................81
Section 4.4 NH Medicaid benefits covered outside the plan ............................84
Section 4.5 Benefits not covered by our plan or New Hampshire
Medicaid ........................................................................................86

Chapter 5. Using NH Healthy Families to help manage your health ......... 88

Section 5.1 Special services and programs .......................................................88
Section 5.2 Care coordination support ..............................................................89
Section 5.3 Continuity of care ..........................................................................90
Section 5.4 Mental health parity assurance.......................................................92

Chapter 6. Rules on prior authorization of services ................................... 94

Section 6.1 Medically necessary services .........................................................94
Section 6.2 Getting plan authorization for certain services ..............................96
Section 6.3 Getting authorization for out-of-network services .........................96
Section 6.4 Out-of-network hospital admissions in an emergency...................97
Section 6.5 Getting family planning services and supplies in- or out-of-
network ..........................................................................................97
Section 6.6 Getting a second medical opinion ..................................................97

Chapter 7. Getting covered prescription drugs .......................................... 99

Section 7.1 Drug coverage rules and restrictions..............................................99
Section 7.2 Plan formulary or drug list ...........................................................101
Section 7.3 Types of drugs we do not cover ...................................................103
Section 7.4 Filling your prescriptions at network pharmacies ........................104
Section 7.5 Drug coverage in facilities ...........................................................106
Section 7.6 Programs to help members use drugs safely ................................107
Section 7.7 Prescription drug copayments ......................................................107

Chapter 8. Asking us to pay ....................................................................... 110

Section 8.1 Network providers may not charge you for covered
services .........................................................................................110
Section 8.2 How and where to send us your request for payment ..................112
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 4

Section 8.3 After the plan receives your request for payment ........................113
Section 8.4 Payment rules to remember .........................................................113

Chapter 9. Your rights and responsibilities .............................................. 114

Section 9.1 Your rights ...................................................................................114
Section 9.2 Your responsibilities ....................................................................115
Section 9.3 Advance care planning for your health care decisions ................117

Chapter 10. What to do if you want to appeal a plan decision or

“action”, or file a grievance ..................................................... 120
Section 10.1 About the appeals process ............................................................120
Section 10.2 How to file a standard appeal and what to expect after you
file (first level appeal) ..................................................................121
Section 10.3 How to file an expedited appeal and what to expect after
you file (first level appeal) ...........................................................123
Section 10.4 How to file a standard State Fair Hearing appeal and what
to expect after you file (second level appeal) ..............................126
Section 10.5 How to file an expedited State Fair Hearing appeal and
what to expect after you file (second level appeal)......................127
Section 10.6 How to request continuation of benefits during appeal and
what to expect afterward ..............................................................130
Section 10.7 How to file a grievance and what to expect after you file ...........131

Chapter 11. Ending your plan membership................................................ 133

Section 11.1 There are only certain times when your plan membership
may end ........................................................................................133
Section 11.2 When you may be involuntarily disenrolled from the plan ........134

Chapter 12. Legal notices ............................................................................. 135

Chapter 13. Acronyms and definitions of important words ....................... 147

Section 13.1 Acronyms ....................................................................................147
Section 13.2 Definitions of important words ...................................................148

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 5

Chapter 1. Getting started as a member

Section 1.1 Welcome

You are enrolled in NH Healthy Families Medicaid Care Management program.

You will get most of your New Hampshire Medicaid health care and prescription drug
coverage through our plan, NH Healthy Families, a New Hampshire Medicaid managed care
plan. Please refer to Section 4.1 (About the Benefits Chart (what is covered)) and 4.2 (Benefits
Chart) for the list of services the plan covers.

NH Healthy Families is contracted with the New Hampshire Department of Health and
Human Services (NH DHHS) to provide the covered services described in the Benefits Chart
in Chapter 4 (Covered services). The plan contracts with a network of doctors, hospitals,
pharmacies, and other providers to provide covered services for plan members. For more
information on using network and out-of-network providers, refer to Chapter 3 (Using NH
Healthy Families for covered services).

As a NH Healthy Families member, you will get your New Hampshire Medicaid health care and
prescription drug coverage through our plan. We also offer health programs designed to help you
manage your special medical and/or behavioral health needs through education and coaching
about your health condition.

This Member Handbook tells you about your healthcare benefits. It is designed to make it easy
for you to make the most of your benefits and services.

Your feedback is important to us. Several times each year, the plan convenes Member Advisory
Council meetings to hear from members like you. If you are interested in joining the plan
Member Advisory Council, let us know by calling Member Services (phone numbers are printed
on the back cover of this handbook).

Section 1.2 What makes you eligible to be a plan member

Medicaid is a joint federal and state program that helps people with limited incomes and
resources receive needed health care coverage.

You are eligible for our plan as long as:

• You are eligible and remain eligible for New Hampshire Medicaid*
• and you live in New Hampshire (the NH Healthy Families service area);
• and you are a United States citizen or are lawfully present in the United States.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 6

If you are pregnant and enrolled in NH Healthy Families when you deliver your baby, your baby
is automatically covered by NH Healthy Families effective on your baby’s date of birth. Contact
NH DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD
Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET when you
deliver your baby or to find out more about New Hampshire Medicaid and its programs.

*Your continued eligibility for New Hampshire Medicaid is re-determined every six to twelve
months. Six weeks before your eligibility is up for renewal you will receive a letter and a
Redetermination Application in the mail from NH DHHS. To ensure there will be no break in
your health care coverage, you must fill out and return the Redetermination Application by the
due date stated in the letter. If you need help to complete the form, contact the NH DHHS
Customer Service Center (Eligibility) toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD
Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET.

Section 1.3 What to expect from the plan

Member Handbook

This Member Handbook describes how the plan works and is in effect beginning January 1, 2019
through each month you are enrolled with NH Healthy Families. The Member Handbook is also
available on our website at [Link].

Your NH Healthy Families membership card – Use it to get all covered services
and prescription drugs

While you are a member of the plan, you must use your NH Healthy Families membership card
whenever you get covered services or prescription drugs. However, even if you do not have your
plan membership card, a provider should never deny care to you. If a provider refuses to treat
you, call our Member Services Department. We will verify your eligibility for the provider.

Here is a sample membership card, as an example:

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 7

As long as you are a member of the plan, you must use your NH Healthy Families
membership card to get covered services. Keep your New Hampshire Medicaid card too.
Present both your plan membership card and New Hampshire Medicaid card whenever you get
services.

If your plan membership card is damaged, lost or stolen, call Member Services right away. We
will send you a new card. (Phone numbers for Member Services are printed on the back cover of
this handbook.)

Welcome Call

Understanding your health and other special needs is important to us.

When you first join NH Healthy Families, we will call to welcome you as a plan member.
During the call, we will explain plan rules and answer any questions you might have about the
plan. As described in the next section, we will explain the importance of completing your Health
Needs Assessment (HNA).

Health Needs Assessment (HNA)

NH DHHS requires us to ask you to complete your Health Needs Assessment (HNA). The
information you provide in the HNA helps us plan and work with you to meet your health care
and functional needs.

The HNA will include questions to identify your medical, behavioral health, functional and other
needs. We will reach out to you to complete the HNA. It can be completed by telephone, or
mail, or via the member secure portal on the NH Healthy Families website. This form is in your
Welcome Packet with a postage-paid envelope. Your completion of the HNA is optional.
However, we encourage you to complete the assessment, and return it to NH Healthy Families.

Explanation of Benefits Notice

From time to time, we will send you a report called the Explanation of Benefits (EOB).

The Explanation of Benefits tells you the total amount you, or others on your behalf, have
spent on a particular service. An Explanation of Benefits is also available when you ask
for one. To get a copy, please contact Member Services. You can also print a copy of
your EOB from our secure member portal at [Link].

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 8

Section 1.4 Staying up-to-date with your personal information

and other insurance information

How to help make sure that we have accurate information about you

Your membership record with the plan has information from NH DHHS, including your address
and telephone number. It is important that you keep your information up to date. Network
providers and the plan need to have correct information to communicate with you as needed.

Let us know about these changes:

• Changes to your name, your address, or your phone number;
• Changes in any other health insurance coverage you have, including:
o An employer’s group health insurance policy for employees or retirees, either for
yourself, or anyone in your household covered under the plan;
o Workers’ Compensation coverage because of a job-related illness or injury ;
o Veteran’s benefits or other government health plan coverage;
o Medicare;
o COBRA or other health insurance continuation coverage. (COBRA is a law that
requires certain employers to let employees and their dependents keep their group
health coverage for a period of time after leaving employment, changes in
employment, and other life events.); or
o If you have any liability claims, such as claims from an automobile accident.
• Changes in your income or other financial support;
• If you have been admitted to a nursing home;
• If you deliver your baby;
• If you receive care in an out-of-area or out-of-network hospital or emergency room; or
• If your guardian, conservator, authorized representative, or personal representative
changes, or if your Durable Power of Attorney is activated.

If any of this information changes, please call Member Services (phone numbers are printed on
the back cover of this handbook) or call the NH Medicaid Service Center toll-free at 1-844-
ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-735-2964), Monday through Friday,
8:00 a.m. to 4:00 p.m. ET.

Member personal health information is kept private

Federal and state laws require that we keep your medical records and personal health information
private. We protect your health information as required by these laws.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 9

Section 1.5 How other insurance works with our plan

Which plan pays first when you have other insurance

Medicaid is the payer of last resort. This means when you have other insurance (like employer
group health coverage or Medicare), they always pay your health care bills first. This is called
“primary insurance”). You must follow all of your primary insurance rules when getting
services. Items or services not covered by your primary insurance and your primary insurance
copayments or deductibles may be covered by NH Healthy Families. For claims to pay correctly,
it is important that you use providers that are in both your primary insurance network and our
network.

When you receive services, tell your doctor, hospital or pharmacy if you have other health
insurance. Your provider will know how to process claims when you have primary insurance and
New Hampshire Medicaid through NH Healthy Families. If you receive a bill for your covered
health care services, refer to Chapter 9 (Asking us to pay).

If you have questions, or you need to update your insurance information, call Member Services
(phone numbers are printed on the back cover of this handbook).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 10

Chapter 2. Important phone numbers and resources

Section 2.1 How to contact NH Healthy Families Member Services

For assistance with coverage questions, finding a provider, claims, membership cards, or other
matters, please call or write to NH Healthy Families Member Services. We will be happy to help
you.

In case of a medical or behavioral health emergency – Dial 911 or go directly to the nearest
hospital emergency room. For a description of emergency services, refer to the Chapter 4
(Benefits Chart).

Method NH Healthy Families Member Services – Contact Information

CALL 1-866-769-3085
Calls to this number are toll-free. Normal business hours of operation
are Monday-Wednesday 8:00 a.m. to 8:00 p.m. and Thursday - Friday
8:00 a.m. to 5:00 p.m.

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.]

Calls to this number are free.

FAX 1-877-502-7255
WRITE NH Healthy Families
2 Executive Park Drive
Bedford, NH 03110

WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 11

Section 2.2 How to contact the plan about a coverage decision or

to file an appeal

A coverage decision is a decision we make about whether a service or drug is covered by the
plan. The coverage decision may also include information about the amount of any prescription
copayment you may be required to pay. If you disagree with our coverage decision, you have the
right to appeal our decision.

An appeal is a formal way of asking us to reconsider and change a coverage decision we have
made. For more information on appeals, refer to Chapter 10 (What to do if you want to appeal a
plan decision or “action’, or file a grievance).

Method Coverage Decision or Appeals – Contact Information

CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours of operation

are Monday-Wednesday 8:00 a.m. to 8:00 p.m. and Thursday - Friday
8:00 a.m. to 5:00 p.m.

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.

Calls to this number are free.

FAX 1-866-270-9943
WRITE NH Healthy Families
2 Executive Park Drive
Bedford, NH 03110
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 12

Section 2.3 How to contact the plan about a grievance

A grievance is the formal name of the process a member uses to make a complaint to the plan
about the plan staff, plan providers, coverage and copayments. For more information on
filing a grievance, refer to Chapter 10 (What to do if you want to appeal a plan decision or
“action”, or file a grievance).

Method Grievance – Contact Information

CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours of

operation are Monday-Wednesday 8:00 a.m. to 8:00 p.m. and
Thursday - Friday 8:00 a.m. to 5:00 p.m.

Member Services also has free language interpreter services

available for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.

Calls to this number are free.

FAX 1-866-270-9943
WRITE NH Healthy Families
Complaint, Grievance and Appeal Department
2 Executive Park Drive
Bedford, NH 03110
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 13

Section 2.4 How to contact the plan about care coordination

Care coordination is the term used to describe the plan’s practice of assisting members with
getting needed services and community supports. Care coordinators make sure participants in the
member’s health care team have information about all services and supports provided to the
member, including which services are provided by each team member or provider. For more
information, refer to Section 5.2 (Care coordination support).

Method Care Coordination – Contact Information

CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours of operation

are Monday-Wednesday 8:00 a.m. to 8:00 p.m. and Thursday - Friday
8:00 a.m. to 5:00 p.m.

Member Services also has free language interpreter services available

for non-English speakers..
TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.

Calls to this number are free.

FAX 1-877-502-7255
WRITE NH Healthy Families
2 Executive Park Drive
Bedford, NH 03110
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 14

Section 2.5 How to contact the plan’s Nurse Advice Line

The Nurse Advice Line is a free 24-hour medical information phone service provided by NH
Healthy Families. Registered nurses are ready to answer your questions 24 hours a day, 365 days
of the year. Contact the Nurse Advice Line when you have questions about the following:

• Medical advice
• Health information library
• Answers to questions about your health
• Advice about an injury or illness
• Help with scheduling PCP appointments

In case of a medical or behavioral health emergency – Dial 911 or go directly to the nearest
hospital emergency room. For a description of emergency services, refer to the Chapter 4
(Benefits Chart).

Method Nurse Advice Line – Contact Information

CALL 1-866-769-3085

Calls to this number are toll-free. The nurse advice line is available 24
hours a day, 7 days a week

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

Calls to this number are free.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 15

Section 2.6 How to request behavioral health services (mental

health or substance use disorder services)

Behavioral health services is another term used to describe mental health and/or substance use
disorder services. Contact NH Healthy Families when you have questions about covered services
and/or network Providers related to behavioral health and substance use disorder services
available under your plan.

In case of a behavioral health emergency – Dial 911 or go directly to the nearest hospital
emergency room. For a description of emergency services, refer to the Chapter 4 (Benefits
Chart).

Method Behavioral Health Services (Mental Health or Substance Use

Disorder Services) – Contact Information
CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours of operation

are Monday-Wednesday 8am to 8pm and Thursday and Friday 8am to
5pm

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

Calls to this number are free.

WRITE NH Healthy Families
2 Executive Park Drive
Bedford, NH 03110
WEBSITE [Link]

If you or someone you know is struggling with addiction and in need of immediate care, contact
the NH Statewide Addiction Crisis Line at 1-844-711-HELP (4357). This 24-hour toll-free crisis
line is available for you or for someone you know who struggles with addiction or substance use.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 16

Section 2.7 How to request non-emergency medical

transportation

Non-emergency medical transportation services are covered for a member who has no other
means of transportation and needs to be transported to and from a New Hampshire Medicaid
covered service as listed in the Benefits Chart in Chapter 4 (Covered services: Transportation
services – Non-emergency medical transportation (NEMT)). (Transportation services – Non-
emergency medical transportation (NEMT)).

Method Non-Emergency Medical Transportation – Contact Information

CALL 1-877-671-6291, Coordinated Transportation Solutions

TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

Calls to this number are free.

FAX Reimbursement Forms only 1-203-375-0516
WRITE Reimbursement Forms only

Coordinated Transportation Solutions

35 Nutmeg Drive, Suite 120
Trumbull, CT 06611
WEBSITE [Link]

Need help getting to an appointment?

If you do not have a car or anyone available to give you a ride, we can help you get to your
medical appointments as well as your state-covered dental appointments. Transportation is
covered for all medically necessary services. Covered transportation services include but are not
limited to:

• Scheduled routine medical appointments

• Transportation from the Emergency Room (non-emergent transportation to the ER is not
covered)
• Transportation from a hospital or other medical facility
• Scheduled state-covered dental appointments
• Pharmacy stops to pick up medications
• Pharmacy stops after being discharged from a hospital
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 17

• Pharmacy stops immediately following a medical appointment

Requests for transportation must be made within two (2) business days but no more than thirty
(30) calendar days in advance of your scheduled appointment(s).

The only exceptions to this rule are for requests such as:

• Urgent trip requests (transport to an Urgent Care Clinic or the appointment has been
evaluated and requested by the Provider to being urgent in nature).
• Hospital discharge requests (discharge nurse at hospital can help with this).
• Regular routine requests considered “indefinite” or “reoccurring” such as: dialysis,
chemotherapy or weekly methadone clinic visits.

What information do I need to know when I call?

• Your Medicaid ID number

• Pick-up/destination address and phone number
• Name of provider/facility you are travelling to
• Appointment date and time, including length of appointment
• Contact phone number where you can be reached by CTS, driver, etc.
• If you use any mobility aids (wheelchair, cane, etc.) or any other equipment in order to
get to appointments.

If you are travelling alone, you must be 16 years of age or older. If you are a minor under the age
of 15, an adult over the age of 18 must accompany you. Additional passengers are allowed for
medical, interpretive, or other relevant support and assistive needs.

Mileage Reimbursement

If you get a ride from someone else (loved one, friend, neighbor etc.), they can be reimbursed for
mileage when transporting you to and from covered medical appointments. Requests for mileage
reimbursement must be made at least two (2) business days prior to your appointment.

What information do I need to know when I call?

• Your Medicaid ID number

• Pick-up/destination address and phone number
• Name of provider/facility they are travelling to
• Appointment date and time
• Who is transporting you to the appointment

A mileage reimbursement form must be filled out by you, signed by the provider’s office staff at
the time of your appointment, and submitted to Coordinated Transportation Solutions (CTS), our
transportation vendor. The mileage reimbursement forms can be requested by calling Member
Services at NH Healthy Families or when speaking to a CTS representative to schedule your trip.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 18

The form is also on our website at [Link]. Choose “Medicaid Plan”, then
“Member Resources”, then “Member Handbooks and Forms”, and then you will find the
“Transportation Reimbursement Form” link.

Section 2.8 How to contact the NH DHHS Customer Service

Center

The New Hampshire Department of Health and Human Services (NH DHHS) Customer Service
Center provides help when you have questions about New Hampshire Medicaid eligibility or
plan enrollment, the other benefits managed directly by NH DHHS as described in Section 4.4
(NH Medicaid benefits covered outside the plan), and when you need a new or replacement New
Hampshire Medicaid card. While the plan can help you with your appeal or grievance, the NH
DHHS Customer Service Center can also provide guidance.

Method NH DHHS Customer Service Center – Contact Information

CALL 1-888-901-4999 (For plan information)
1-844-ASK-DHHS (1-844-275-3447) (For all other calls)

Calls to this number are toll-free. Office hours are Monday through
Friday, 8:00 a.m. to 4:00 p.m. ET.

Free language interpreter services are available for non-English

speakers.
TTY/TDD 1-800-735-2964

Calls to this number are free. This number requires special telephone
equipment and is only for people who have difficulties with hearing or
speaking.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 19

Section 2.9 How to contact the NH Long-Term Care Ombudsman

The New Hampshire Long-Term Care Ombudsman assists with complaints or problems related
to coverage of long-term health care facility (also referred to as nursing facility) services covered
directly by NH DHHS. Before contacting the Long-term Care Ombudsman when you have a
problem related to plan covered services, seek resolution through the NH DHHS Customer
Service Center.

Method NH Long-Term Care Ombudsman – Contact Information

CALL 1-800-442-5640

Calls to this number are toll-free. Office hours are Monday through
Friday, 8:30 a.m. – 4:30 p.m. ET.
TTY/TDD TDD Access Relay (NH): 1-800-735-2964

Calls to this number are free. This number requires special telephone
equipment and is only for people who have difficulties with hearing or
speaking.
FAX 603-271-5574
WRITE Office of the Long-Term Care Ombudsman
Office of the Commissioner
NH Department of Health and Human Services
129 Pleasant Street
Concord, NH 03301
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 20

Section 2.10 How to contact the NH DHHS Ombudsman

The New Hampshire Department of Health and Human Services (NH DHHS) Ombudsman
assists plan members, clients, Department employees, and members of the public to resolve
disagreements, including complaints or problems involving Medicaid eligibility or coverage.
Before contacting the NH DHHS Ombudsman when you have a problem related to your plan,
seek resolution through the plan’s appeal and grievance processes described in Chapter 10 (What
to do if you want to appeal a plan decision or “action”, or file a grievance).

Method NH DHHS Ombudsman – Contact Information

CALL 1-800-852-3345, ext. 6941

Calls to this number are toll-free. Office hours are Monday through
Friday, 8:30 a.m. – 4:30 p.m. ET.
TTY/TDD TDD Access Relay (NH): 1-800-735-2964

Calls to this number are free. This number requires special telephone
equipment and is only for people who have difficulties with hearing or
speaking.
FAX 603-271-4632
WRITE Office of the Ombudsman
Office of the Commissioner
NH Department of Health and Human Services
129 Pleasant Street
Concord, NH 03301
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 21

Section 2.11 How to contact ServiceLink Aging & Disability

Resource Center

ServiceLink is a NH DHHS program that helps individuals identify and access long-term
services and supports, access family caregiver information and supports, and learn about
Medicare and Medicaid benefits. ServiceLink is a program supported by NH DHHS.

Method ServiceLink Aging & Disability Resource Center – Contact

Information
CALL 1-866-634-9412

Calls to this national number are toll-free. Calls made to the number
from some cell phones and outside of New Hampshire will be directed
to the NH DHHS Customer Service Center. When you reach that office,
you will be transferred to the number of the appropriate ServiceLink
location for your area

Office hours are Monday through Friday, 8:30 a.m. - 4:30 p.m. ET.

Free language interpreter services are available for non-English

speakers.
TTY/TDD Call the number above or visit the website below for TTY/TDD
services for your local office.
FAX Call the number above or visit the website below for the fax number of
your local office.
WRITE Call the number above or visit the website below for the address of your
local office
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 22

Section 2.12 How to report suspected cases of fraud, waste

or abuse

You play a vital role in protecting the integrity of the New Hampshire Medicaid program. To
prevent and detect fraud, waste and abuse, NH Healthy Families works with NH DHHS,
members, providers, health plans, and law enforcement agencies. (For definitions of fraud, waste
and abuse, refer to Section 13.2 (Definitions of important words).)

Examples of fraud, waste and abuse include:

• When you get a bill for health care services you never received.
• Lack of information in member health record to support services billed.
• Loaning your health insurance membership card to others for the purpose of receiving
health care services, supplies or prescription drugs.
• Providing false or misleading health care information that affect payment for services.

If you suspect Medicaid fraud, waste, or abuse, report it immediately. Anyone suspecting a New
Hampshire Medicaid member, provider, or plan of fraud, waste, or abuse may also report it to the
plan and/or the New Hampshire Office of the Attorney General. You do not have to give your
name. You may remain anonymous.

Method NH Healthy Families to report fraud, waste or abuse – Contact

Information
CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours of operation

are Monday-Wednesday 8 am to8 pm and Thursday and Friday 8 am to
5 pm

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.

Calls to this number are free.

WRITE NH Healthy Families
2 Executive Park Drive
Bedford, NH 03110
WEBSITE [Link]
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 23

Method New Hampshire Office of the Attorney General to report fraud

waste or abuse – Contact Information
CALL 603-271-3658

Office hours are Monday through Friday, 8:00 a.m. - 5:00 p.m. ET.
TTY/TDD TDD Access Relay (NH): 1-800-735-2964

Calls to this number are free. This number requires special telephone
equipment and is only for people who have difficulties with hearing or
speaking.
FAX 603-271-2110
WRITE Office of the Attorney General
33 Capitol Street
Concord, NH 03301
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 24

Section 2.13 Other important information and resources

• You may designate an authorized representative or personal representative – You
may designate a person to whom you give authority to act on your behalf. Your
representative will be able to provide the plan with information or receive information
about you in the same manner that the plan would discuss or disclose information directly
to you. To have someone represent you, you must authorize your representative in
writing and tell us how they may represent you. Your authorized representative or
personal representative designation is valid until you revoke or amend it in writing. For
more information, contact Member Services (phone numbers are printed on the back
cover of this handbook.)

• Alternative formats and interpretation services – Plan information is available in

alternative formats for those members with limited reading abilities or who require
interpretation services. If you need materials in an alternative format or require free
interpretation services for covered services listed in the Benefits Chart in Chapter 4,
contact Member Services (phone numbers are printed on the back cover of this
handbook).
o If you are eligible for Medicaid, we are required to give you information
about the plan’s benefits that is accessible and appropriate for you at no
cost. Information is available in Braille, in large print, and other formats.
o Interpretation services are also available. To arrange interpretation
services or get information from the plan in a way that works for you,
please call Member Services (phone numbers are printed on the back
cover of this handbook).
o If you have any trouble getting information from our plan because of
problems related to language or a disability, please report the problem to
the NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-
275-3447) (TDD Access Relay: 1-800-735-2964), Monday through
Friday, 8:00 a.m. to 4:00 p.m. ET.
• Information about the structure and operation of the plan – Physician Incentive Plan
NH Healthy Families encourages our providers to offer you the best care. You have the
right to request and receive the plan we use to offer incentives to the providers in our
network.
• Information about plan provider incentives and payment arrangements – To request
information about our provider incentives or payment arrangements, contact Member
Services (phone numbers are printed on the back cover of this handbook). Provider
incentives and payment arrangements describe how network providers are paid for
covered services, including any payment bonuses they may be eligible to receive based
on patient outcomes or other performance measures.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 25

• Member material requests – Contact NH Healthy Families Member Services to request

a copy of our Member Handbook, Drug List, or Provider Directory. Document(s) will be
sent within five (5) business days of your request. (Phone numbers for Member Services
are printed on the back cover of this Handbook.)

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 26

Chapter 3. Using NH Healthy Families for covered services

This chapter explains what you need to know about accessing covered services under the plan.
It gives definitions of select terms and explains the rules you will need to follow to get health
care services covered by the plan. For more definitions, refer to Section 13 (Acronyms and
definitions of important words).

NH Healthy Families will work with you and your primary care physician (PCP) to ensure you
receive medical services from specialists trained and skilled in your unique needs, including
information about and access to specialists within and outside the plan’s provider network, as
appropriate.

For information on what services are covered by our plan, refer to the Benefits Chart in Chapter
4. The Medicaid covered services in the Benefits Chart are supported by New Hampshire
Department of Health and Human Services rules (Chapters He-W, He-E, He-C, He-M, and He-
P). The rules are available online at
[Link]

What are “network providers” and “covered services”?

Here are some definitions that can help you understand how you get the care and services
covered for you as a member of our plan:
• “Providers” are doctors and other health care professionals licensed by the state to
provide medical services and care. The term “providers” also includes hospitals and other
health care facilities, as well as pharmacies.
• “Network providers” are the doctors, pharmacies and other health care professionals,
medical groups, hospitals, durable medical equipment suppliers, and other health care
facilities that have an agreement with the plan to accept our payment and your
prescription copayment, if any, as payment in full. The providers in our network bill us
directly for care they give you.
• “Covered services” include all health care services, prescription drugs, supplies, and
equipment covered by our plan. Refer to the Benefits Chart in Chapter 4 for a list of
covered services.

Rules for getting your health care services and prescriptions covered by the plan

NH Healthy Families covers all services required in our contract with NH DHHS.

NH Healthy Families will generally cover your health care as long as:
• The care you receive is included in the plan’s Benefits Chart (this chart is in Chapter
4 of this handbook).
• The care you receive is considered medically necessary. “Medically necessary” means
that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment
of your medical condition and meet accepted standards of medical practice. For more
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 27

information about medically necessary services, refer to Section 6.1 (Medically necessary
services).
• You receive approval in advance from the plan before receiving the covered service,
if required. Prior authorization requirements for covered services are in italics in Section
4.2 (Benefits Chart).
• You have a network primary care provider (a PCP) who is providing and
overseeing your care. As a member of our plan, you must choose a network PCP (for
more information about this, see Section 3.1 (Your Primary Care Provider (PCP)
provides and oversees your medical care)
o In some situations, your network PCP may give you a recommendation in advance before
you use other providers in the plan’s network, such as specialists, behavioral health
providers, hospitals, skilled nursing facilities or home health care agencies. A written
referral is not required to see participating providers. Your provider may submit a
“prior authorization” to the plan to request approval of specific services. For more
information, refer to Chapter 6 (Rules for accessing covered services). Please refer to
your provider directory to find in-network specialty care and behavioral health care
providers as well as in hospitals.
o Authorizations from your PCP are not required for emergency care or urgently needed
services. There are also some other kinds of care you can get without having approval
in advance from your PCP (for more information, refer to Section 4.2 (Benefits Chart).
• The care you receive is from a network provider (for more information, refer to
Section 3.3 (How to get care from specialists and other network providers). Most care
you receive from an out-of-network provider (a provider who is not part of our plan’s
network) will not be covered, except with prior approval from the plan or for emergency
services. For more information about when out-of-network services may be covered,
refer to Section 3.5 (Getting care from out-of-network providers).

Here are four exceptions:

o The plan covers emergency care or urgently needed services that you get from an
out-of-network provider. For more information about emergency or urgently needed
services, refer to Section 3.6 (Emergency, urgent and after-hours care).
o If you need medical care that New Hampshire Medicaid requires our plan to cover
and the providers in our network cannot provide this care, you can get this care from an
out-of-network provider. For information about getting approval to see an out-of-
network doctor, refer to Section 6.3 (Getting out-of-network services).
o The plan covers kidney dialysis services that you get at a New Hampshire
Medicaid participating, Medicare-certified dialysis facility when you are temporarily
outside the plan’s service area. For more information, contact Member Services (phone
numbers are printed on the back cover of this handbook).
o For covered family planning services, you may see any New Hampshire Medicaid
participating doctor, clinic, community health center, hospital, pharmacy or family-

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 28

planning office. For more information, refer to “Family planning services” in the
Benefits Chart in Chapter 4 (Covered services).

Section 3.1 Your Primary Care Provider (PCP) provides and

oversees your medical care

What is a “PCP” and what does the PCP do for you?

A PCP is the network provider you choose (or is assigned to you by the plan until you select one)
and who you should see first for most health problems. He or she makes sure you get the care
you need to keep you healthy. He or she also may talk with other doctors and providers about
your care. Your PCP has the responsibility for supervising, coordinating, and providing your
primary health care. He or she initiates referrals for specialist care, and maintains the continuity
of your care.

Your PCP may include a network Pediatrician, Family Practitioner, General Practitioner,
Internist, Obstetrician/Gynecologist, Physician Assistant (under the supervision of a physician),
or Advance Practice Registered Nurse (APRN). If you need help selecting or changing your
PCP, call Member Services (phone numbers are printed on the back cover of this handbook).

• What is a PCP? A PCP is a doctor who oversees all of your care.

• What types of providers may act as a PCP? Can a specialist be a PCP? Pediatricians,
Family/General Practitioners, Internal Medicine, Obstetricians/Gynecologists, Registered
Nurse Practitioners, Physician Assistant (under the supervision of a physician), and
Advanced Registered Nurse Practitioners (ARNP) can all serve as your PCP. Specialists
can be your PCP for special needs upon request, contact Member Services for more
information.

• What is the role of a PCP in your plan? A Primary Care Provider (PCP) is your point
person for your health care needs. These doctors or nurse practitioners help take care of
the basics of health care, focusing on wellness and prevention. The PCP is your primary
partner for your health.

• What is the role of a PCP in coordinating covered services? Your PCP will refer you to
specialists who can assist with coordinating your care that is medically necessary. It is
your responsibility to make sure that the providers you receive services from are in
network with NH Healthy Families. Contact Member Services for assistance.

• What is the role of the PCP in making decisions about or obtaining prior authorization?
Your PCP is responsible for obtaining any prior authorizations that may be needed for
specialty care and other services based on your medical need.

• Can you have a PCP that is not in the NH Healthy Families’ network? The PCP you
select must be within our network.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 29

• Can you choose to go to another doctor who is not your PCP? You may visit any
provider that is within our network for medical needs.

• What are NH Healthy Families referral requirements? NH Healthy Families does not
require any written referrals from your PCP as long as the service(s) recommended by
your PCP or Specialist is medically necessary.

How do you choose your PCP?

The Provider Directory is a list of all the providers in our network. Our network includes,
doctors, pharmacies and hospitals. The Provider Directory also provides information about
specialist providers and behavioral health providers.

When picking a PCP, look for one of the following kinds of providers:

• Pediatricians
• Family /General Practitioners
• Internal Medicine
• Obstetricians/Gynecologists
• Registered Nurse Practitioners
• Physician Assistants (under the supervision of a physician)
• Advanced Registered Nurse Practitioners (ARNP)

*Specialists can be your PCP for special needs upon request.

We are always working for our members to build the best provider network. You can check our
online Provider Directory at [Link] to see if new providers have been
added. Upon request, a specialist can be your PCP for special needs.

If you do not choose a PCP, we will automatically assign one to you based on your address on
file and the PCP availability in your area.

Want to learn more about a provider before you choose? Call Member Services at
1-866-769-3085.

Changing your PCP

You may change your network PCP for any reason, at any time. Also, if your PCP leaves the
plan’s provider network, you may have to find a new PCP. For more information about what
happens when your provider leaves the network, refer to Section 3.4 (What happens when a
PCP, specialist or another network provider leaves our plan’s network).

You must notify us when you change your PCP. You can do this by:
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 30

• Calling member services at 1-866-769-3085

• Going online. Visit the Member Secure Portal at [Link]
Your PCP change will be effective the next day.

Section 3.2 Services you can get without getting approval

in advance

You can get the services listed below without getting approval in advance from your PCP or NH
Healthy Families.

• Routine women’s health care, including breast exams, screening mammograms (X-rays
of the breast), pap tests, pelvic exams, and maternity care.
• Flu shots.
• Emergency services from network providers or from out-of-network providers.
• Urgently needed services from network providers or from out-of-network providers
when network providers are temporarily unavailable or inaccessible (e.g., when you are
temporarily outside of the plan’s service area).
• Family planning services when you go to any participating New Hampshire Medicaid
family planning provider.
• Any preventative care service

Section 3.3 How to get care from specialists and other network
providers

It is important to know which providers are included in our network. With some exceptions, the
plan will only pay for your services if you use network providers required by the plan to get your
covered services. The only exceptions are emergencies and for urgently needed services when
the network is not available or when you receive authorization in advance from the plan to see an
out of network provider.

A specialist is a doctor who provides health care services for a specific disease or a specific part
of the body. When your PCP thinks that you need a specialist, he or she will refer you (or hand-
off your care) to a network specialist. There are many kinds of specialists. Here are a few
examples:

• Oncologists care for patients with cancer.

• Cardiologists care for patients with heart conditions.
• Orthopedists care for patients with certain bone, joint or muscle conditions.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 31

You may request a copy of the Provider Directory from Member Services. (Phone numbers are
printed on the back cover of this handbook). The Provider Directory lists network providers.
Also, you may ask Member Services for more information about our network providers,
including their qualifications.

You can also see the Provider Directory at [Link] or

download it from this website. Both Member Services and the website can give you the most up-
to-date information about changes in our network providers.

When your PCP thinks that you need specialized treatment, he or she will give you a referral
(approval in advance) to see a network specialist or certain other providers. For some types of
referrals, your PCP may need to get approval in advance from our plan. (This is called getting
“prior authorization.” Prior authorization requirements for covered services are in italics in
Section 4.2 (Benefits Chart).

It is very important to get a referral (approval in advance) from your PCP before you see a
network specialist or certain other providers.

It is important to know which providers are included in our network. With some exceptions, the
plan will only pay for your services if you use network providers required by the plan to get your
covered services. The only exceptions are emergencies and for urgently needed services when
the network is not available or when you receive authorization in advance from the plan to see an
out of network provider.

Your PCP will refer you to specialists who can assist with coordinating your care that is
medically necessary. It is your responsibility to make sure that the providers you receive services
from are in network with NH Healthy Families. Contact Member Services for assistance. If there
are no local in- network providers to assist with your care, your PCP can work with our plan to
obtain a prior authorization to receive the services outside of the plan network.

A Prior Authorization Request is submitted by your PCP, specialist or facility to request certain
medically necessary services/procedures. This request is processed by a Referral Specialist (RS)
who reviews the information submitted and builds an authorization. The RS may reach out to the
requesting provider for additional information that is required. The request is then sent to a nurse
for review.

• The nurse reviews the clinical information and compares it to the current state policy,
corporate clinical policy and InterQual Medical necessity criteria. If the information is
complete and criteria is met, the request will be approved. The nurse will then issue an
approval letter to the requesting provider, you the member, and the
facility/office/servicing provider. This approval recognizes that the request is medically
necessary.
• If the nurse reviews the clinical information and it does not meet the criteria, the request
is sent to a Medical Director (MD) to review. The MD will review all information
provided and this review may result in an approval or denial.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 32

• If denied, the MD’s denial reason will be shared in the denial letter as well as any
medical policy utilized to make the decision. NH Healthy Families notifies the requesting
provider of the denial within 24 hours by phone. During this call, the nurse will provide a
verbal notification of the denial and how the provider can request a Peer-to-Peer review,
as well as your appeal rights.
• A denial letter is issued after verbal notification is given and is sent to both the requesting
provider and you the member.
• A Peer-to-Peer review is a conversation between the requesting provider and our Health
Plan Medical Director. This allows for further discussion about your individual case and
additional clinical information may be provided to the MD. This may or may not result in
an approval.

Family Planning

NH Healthy Families covers family planning services. You can get these services and supplies
from providers that are not in our network. You do not need a prior authorization. These services
are free to our members. These services are voluntary and confidential. Some examples of family
planning services are:

• Education and advice from a trained personnel to help you make choices
• Information about birth control
• Physical exams
• Follow-up visits
• Immunization services
• Pregnancy tests
• Birth control supplies
• Tests and treatment of STDs

Vision

NH Healthy Families allows members to choose from a standard selection of frames and lenses.
Members can choose to opt out of the standard benefit and select frames outside of the standard
selection. An amount will be given to you as a credit. You can use this to buy glasses with single
vision lenses, or glasses with bifocal or trifocal lenses. You will have to pay for any charges that
go over the allowed amount. Contact member services to find out the amount you have as credit.

Dental services

The plan does not cover dental services. The services are managed through NH Medicaid. For
questions about your dental benefits, contact the NH Medicaid Customer Service Center. Refer
to Section 2.8 (How to contact the NH DHHS Customer Service Center) for contact information
and refer to Section 4.4 (NH Medicaid benefits covered outside the plan).

Fluoride varnish services are covered by the plan for some members. Refer to Fluoride varnish
in this Benefits Chart.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 33

Behavioral health services

The plan covers inpatient and outpatient mental health services. For specific details refer to
Section 4.2 (Benefits chart). Inpatient services include:

• Inpatient mental health services to evaluate and treat an acute psychiatric condition
• Rehabilitation services (managed residential services)*
• Psychiatric consultation on an inpatient medical unit*

Outpatient mental health services are covered when provided by a community mental health
center, psychiatrist, psychiatric advance practice registered nurse (APRN), mental health therapy
provider, psychologist, licensed psychotherapy provider, community health center, federally
qualified health center (FQHC), rural health center (RHC), and outpatient mental health
facilities.

Covered services include:

• Medication visits
• Individual, group and family therapy
• Diagnostic evaluations
• Partial hospitalization program (PHP)*
• Intensive outpatient program (IOP)*
• Emergency psychiatric services
• Electroconvulsive Therapy (ECT)*
• Transcranial Magnetic Stimulation *
• Crisis intervention
• Individualized Resiliency and Recovery Oriented Services (IROS)
• Case Management services, including Assertive Community Treatment (ACT)
• Psychological testing*

*Indicates a service that requires a Prior Authorization

Section 3.4 What happens when a PCP, specialist or another

network provider leaves our plan

We may make changes to the hospitals, doctors, and specialists (providers) that are part of our
plan during the year. Also, sometimes your provider might leave the network. If your doctor or
specialist leaves our plan, you have certain rights and protections described below:
• When possible we will notify you when your PCP or other provider who you receive
routine treatment from leaves the plan’s network. We will notify you the earlier of fifteen
(15) calendar days after the plan receives notice of your provider leaving the network, or
fifteen (15) calendar days prior to the effective date of the provider termination so that
you have time to select a new provider.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 34

• We will assist you in selecting a new qualified provider to continue managing your health
care needs.
• If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted. NH Healthy Families may approve visits with your doctor for up to 90 days
after he/she leaves the network. During this time, we will help you find a new doctor. If
your provider has been terminated because of a quality of care issue, this option is not
available. Your doctor must agree to:
o Treat your healthcare needs
o Accept the same payment rate from NH Healthy Families
o Follow NH Healthy Families’ quality assurance standards
o Follow NH Healthy Families’ policies about prior authorization and use a
treatment plan
o Provide necessary medical information to you
• If you believe we have not furnished you with a qualified provider to replace your
previous provider or that your care is not being appropriately managed, you have the
right to file a grievance or an appeal of our decision.
• If you find out your doctor or specialist is leaving our plan, please contact us so we can
assist you in finding a new provider to manage your care.
• You may choose your preferred network health providers to the extent possible and
appropriate. We will assign you to another PCP if you do not select one prior to the
effective date of the PCP termination.
• You can change your PCP by calling Member Services at 1-866-769-3085 or going
online via the member secure portal at [Link]
• If you are receiving a prior authorized ongoing course of treatment with a participating
provider who becomes unavailable to continue to provide services, the plan shall notify
you in writing within seven (7) calendar days from the date the plan becomes aware of
such unavailability and will develop a transition plan to help you with your continued
ongoing care.

Section 3.5 Getting care from out-of-network providers

If you are an American Indian or Alaska Native (AI/AN) of a federally recognized tribe or
another individual determined eligible for Indian health care services, special coverage rules
apply. You may get out-of-network services at an Indian health facility without prior
authorization. Contact Member Services for more information (phone numbers are printed on the
back cover of this handbook).

When you receive prior authorization from the plan for treatment from an out-of-network
provider, you should never be charged more than a prescription drug copayment, if any, for
covered services. If you are charged for covered services, please contact Member Services
(phone numbers are printed on the back cover of this handbook).
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 35

Section 3.6 Emergency, urgent, and after-hours care

What is a “medical emergency” and what should you do if you have one?
A “medical emergency” is when you, or any other reasonable person with an average
knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a body
organ or part. Or in the case of a pregnant women in active labor, meaning labor at a time when
there is not enough time to safely transfer you to another hospital before delivery, or the transfer
may pose a threat to your health or safety or to that of your unborn child.

If you have a medical emergency:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP.
• As soon as possible, make sure that our plan has been told about your emergency.
We need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours of the onset of the emergency. This
helps your PCP to provide or arrange for any follow-up care that you may need. We can
also help you get follow-up care. Call Member Services at 1-866-769-3085 (TDD/TYY
1-855-742-0123, Relay 711).

What is covered if you have a medical emergency?

You may get covered emergency medical care whenever you need it, anywhere in the United
States or its territories. Emergency care is not covered outside of the United States or its
territories. The plan covers ambulance services in situations where you, or any other reasonable
person with an average knowledge of health and medicine, believe getting to the emergency
room in any other way could endanger your health.

If you have an emergency, the Plan or your PCP will talk with the doctors who are giving you
emergency care to help manage and follow-up on your care. The doctors who are giving you
emergency care will decide when your condition is stable and the medical emergency is over.

After the emergency is over, you are entitled to follow-up care to be sure your condition
continues to be stable. Your follow-up care will be covered by our plan. If an out-of-network
provider provides your emergency care, the plan or your PCP will work with you as needed to
arrange for network providers to take over your care as soon as your medical condition and
the circumstances allow.

For more information, refer to the Benefits Chart (Emergency medical care) in Chapter 4 of
this handbook.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 36

What if it wasn’t a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it was not a medical emergency after all.

Examples of medical emergencies include:

• Broken bones
• Convulsions or seizures
• Severe chest pain or heart attack
• Serious accidents
• Stroke (symptoms often include facial droop, speech difficulty)
• Loss of consciousness
• Heavy bleeding
• Severe headaches or other pain
• Vomiting blood or continuous vomiting
• Fainting or dizzy spells
• Poisoning
• Shock (symptoms often include sweating, feeling thirsty, dizzy, pale skin)
• Severe burns
• Trouble breathing
• Sudden inability to see, move, or speak
• Suicidal thoughts, plans and/or actions
• First experience of auditory or visual hallucinations

If it turns out that it was not an emergency, as long as you reasonably thought your health was in
serious danger, we will cover your care. However, after the doctor has said that it was not an
emergency, we will cover additional care only if you get the additional care in one of these two
ways:

• You go to a network provider to get the additional care;

• – or – The additional care you get is considered “urgently needed services” and you
follow the rules for getting these services. For more information see the information
below titled, “What if you are in the plan’s service area when you have an urgent need
for care after normal business hours” and “What if you are outside the plan’s service
area when you have an urgent need for care?”.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 37

What is a “behavioral health emergency”

A “behavioral health emergency” is an emergent situation in which someone is in need of
behavioral health assessment and treatment in a safe and therapeutic setting, is a danger to
themselves or others, or exhibits significant behavioral deterioration rendering the member
unmanageable and unable to cooperate in treatment.

If you have a behavioral health emergency or mental health crisis:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP.
• If you are experiencing a mental health crisis, call Member Services at 1-866-769-
3085 24 hours a day, 365 days a year.
A mental health crisis is any situation in which a person’s behaviors puts them at risk of
hurting themselves or others, and/or when they are not able to resolve the situation with
the skills and resources available. Many things can lead to a mental health crisis
including, increased stress, physical illness, problems at work or at school, changes in
family situations, trauma/violence in the community or substance use. These issues are
difficult for everyone, but they can be especially hard for someone living with a mental
illness.
• As soon as possible, make sure that our plan has been told about your emergency.
We need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. Call Member Services 24 hours a
day, 365 days a year (the phone number is located on our Member ID Card and on the
back cover of this handbook.)

What if you or someone you know struggles with addiction or substance use?

NH Healthy Families understands that addiction is a disease and that access to immediate help is
critical to recovery.

• If you are a NH Healthy Families member struggling with addiction and are in need of
urgent care, contact the phone number on your Member ID Card or call Member
Services; or
• If someone you know struggles with addiction or substance use, call the 24-hour toll-free
NH Statewide Addiction Crisis Line at 1-844-711-HELP (4357).

What if you are in the plan’s service area when you have an urgent need for care
after normal business hours?

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness,
injury, or a condition that requires immediate medical care to prevent a worsening of health due
to symptoms that a reasonable person would believe are not an emergency but do require
medical attention. You should always try to obtain urgently needed services from network

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 38

providers. However, if providers are temporarily unavailable and it is not reasonable to wait to
obtain care from a network provider, we will pay for the covered service(s) provided to you.

Here are some examples of when to go to the ER and when NOT to go to the ER:

When you need urgent care, follow these steps:

• Call your PCP. Your PCP may give you care and directions over the phone. If it is after
hours and you cannot reach your PCP, call NH Healthy Families at 1-866-769-3085
(TDD/TTY 1-855-742-0123, Relay 711) and say “Nurse”. You will be connected to a
nurse. Have your NH Healthy Families ID card number handy. The nurse may help you
over the phone or direct you to other care. You may have to give the nurse your phone
number. During normal office hours, the nurse will assist you in contacting your PCP.
• If you are told to see another doctor or go to the nearest hospital emergency room, bring
your NH Healthy Families ID card. Ask the doctor to call your PCP or NH Healthy
Families.

If you are not sure what to do, remember these tips:

• If you can, call your doctor first.

• If your condition is severe, call 911 or go to the nearest hospital. You do not need
a doctor’s approval. Also, you can use any hospital in an emergency, even if it is not
in our network.
• Not sure if it is an emergency? Call your PCP. Your PCP will tell you what to do. If
your PCP is not available, a doctor taking calls can help. There may be a message
telling you what to do.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 39

• Call Our 24-hour nurse advice line 1-866-769-3085 (TDD/TTY 1-855-742-0123,

Relay 711) and say “Nurse” if you have questions.
• Urgent Care is not Emergency Care.
• Emergency rooms are for emergencies.

It is important that, you or someone acting on your behalf MUST call your PCP and NH Healthy
Families within 48 hours of admission. This helps your PCP to provide or arrange for any
follow-up care that you may need. We can also help you get follow-up care. Call us 1-866-769-
3085 (TDD/TTY 1-855-742-0123, Relay 711).

What if you are outside the plan’s service area when you have an urgent need for
care?

When you are outside the service area and cannot get care from a network provider, our plan will
pay for urgently needed covered services that you get from any provider. However, our plan does
not cover urgently needed services or any other services if you receive the care outside of the
United States or its territories.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 40

Chapter 4. Covered services

Section 4.1 About the Benefits Chart (what is covered)

This chapter describes what services NH Healthy Families covers. You can obtain covered
services from the plan’s provider network, unless otherwise allowed as described in this
handbook. Some covered services require prior authorization from the plan. Prior authorization
requirements for covered services are in italics in Section 4.2 (Benefits Chart).

The Benefits Chart in this chapter explains when there are limits or prior authorization
requirements for services. The Medicaid covered services in the Benefits Chart are supported by
New Hampshire Department of Health and Human Services rules (Chapters He-W, He-E, He-C,
He-M, and He-P). The rules are available online at
[Link]

About covered services:

• The Benefits Chart lists the services NH Healthy Families covers. The chart is for your
general information and may not include all the benefits available to you. Please call NH
Healthy Families Member Services with questions about your services (phone numbers
are printed on the back cover of this handbook).
• The services listed in the Benefits Chart are covered only when the following
requirements are met:
o The services meet the coverage guidelines established by New Hampshire Medicaid.
o The services are medically necessary. For more information about medically
necessary services, refer to Section 6.1 (Medically necessary services).
o The services are provided by network providers, unless otherwise allowed as
described in this handbook. In most cases, care you receive from an out-of-network
provider will not be covered unless you have received prior authorization from the
plan. For more information about using in-network and out-of-network providers,
refer to Chapter 3 (Using NH Healthy Families for covered services).
o You have a primary care provider (a PCP) who is providing and overseeing your care.
Some of the services listed in the Benefits Chart in this chapter are covered only if
your doctor or other network provider gets approval in advance (sometimes called
“prior authorization”) from us. Covered services that need authorization in advance
are marked in italics in the Benefits Chart.
• You pay nothing, except for any applicable copayments, for the covered services
described in the Benefits Chart as long as you follow the plan’s rules described in this
handbook. Currently you are only responsible for the copayment for your covered
prescription drugs.
• New Hampshire Medicaid benefits may change over time. You will be notified of those
changes.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 41

If you have questions about covered services, call Member Services (phone numbers are printed
on the back cover of this handbook).

Section 4.2 Benefits Chart

Services covered by the plan

Abdominal aortic aneurysm screening

The plan covers a one-time ultrasound screening for men aged 65-75 year who have never
smoked.
Prior authorization is not required for services provided by a network provider.
For more information, please call Member Services.

Abortion services
The plan covers abortion services only as follows:

• If the pregnancy is the result of rape or incest; or

• In the case of a woman who has a physical disorder, physical injury or physical illness
(including a life-endangering physical condition caused by or arising from the pregnancy
itself) that would, as certified by a physician, endanger the life of the woman unless an
abortion is performed. Voluntary termination of pregnancy is not covered.

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 42

Services covered by the plan

Adult medical day care services

The plan covers services provided by licensed adult medical day care providers. Services are
provided to adults aged 18 years and older who otherwise live in an independent living situation.

Participants must require adult medical day care services for a minimum of four (4) hours per
day on a regularly occurring basis, but services are not covered for more than 12 hours per day
on a regularly occurring basis.

Covered services include:

• Nursing services and health supervision

• Maintenance level therapies
• Nutritional and dietary services
• Recreational, social, and cognitive activities
• Assistance with activities of daily living
• Medical supplies
• Health and safety services

Prior authorization is required.

For more information, please call Member Services.

Alcohol misuse screening and counseling

Refer to Substance use disorder (SUD) treatment services in this Benefits Chart.

Allergy testing and treatment

The plan covers allergy testing when significant symptoms exist and conventional therapy has
not worked. Allergy testing focuses on determining what allergens cause a particular reaction,
the degree of the reaction and informs treatment options.

Covered testing services include the professional service to prepare and to administer an
allergenic extract.

If an allergen is identified, covered allergy treatment includes medication and immunotherapy

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 43

Services covered by the plan

Ambulance services – Emergency

The plan covers ambulance services when you have an emergency medical condition and when
other modes of transportation could risk your health or your life.

Covered ambulance services include:

• Ground ambulance services; and

• Air ambulance services if:
o You cannot safely be transported in a timely basis via ground transportation; and
o You are at imminent risk of losing life or limb, if the fastest means of transport is
not utilized.

Emergency ambulance services will take you to the nearest facility that can provide you
appropriate care.

Prior authorization is not required for emergency ambulance services.

Ambulance services are not covered outside the United States and its territories.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 44

Services covered by the plan

Ambulance services – Non-emergency

The plan covers non-emergency ambulance services to appointments for Medicaid-covered

services covered by the plan when other modes of transportation would likely endanger your
health and safety.

Covered ambulance services include:

• Ground ambulance services

• Air ambulance services if:
o You cannot safely be transported in a timely basis via ground transportation; and
o You are at imminent risk of losing life or limb, if the fastest means of transport is
not utilized

Services are managed by CTS (Coordinated Transportation Solutions) for the plan. You can
arrange for transportation by calling CTS at 1-877-671-6291.

Prior authorization from the plan is required for non-emergency ambulance services.

Ambulance services are not covered outside the United States and its territories.

For more information, please call Member Services.

Anesthesia

Refer to Physician services in this Benefits Chart.

Audiologist services

The plan covers hearing tests and hearing aid evaluations to determine if a hearing aid is needed.
Hearing aid evaluations or hearing aid consultations performed by an audiologist are limited to
one every 24 months for members over 21 years old, and as needed for members under age 21
years.
Prior authorization from the plan is not required for services provided by a network provider.
Refer to “Hearing services” for more information on related services and hearing aids.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 45

Services covered by the plan

Bariatric surgery (weight loss surgery)

The plan covers a variety of bariatric surgical procedures to treat obesity.

To be eligible a person must have a body mass index (BMI) of more than 35 and a severe obesity
related health condition, such as diabetes, sleep apnea, high blood pressure, or heart disease.
Prior authorization from the plan is required.
For more information, please call Member Services.

Behavioral health services

Refer to Inpatient mental health services in this Benefits Chart.

Refer to Outpatient mental health services in this Benefits Chart.
Refer to Substance use disorder (SUD) treatment services in this Benefits Chart.

Bone mass measurement

The plan covers certain bone mass measurement procedures.

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

Breast cancer screening (mammogram)

The plan covers mammograms and clinical breast exams for women aged 40 years and older
every one to two years. More frequent mammograms and breast exams may be provided when
ordered by your PCP.
Prior authorization from the plan is not required for screenings provided by a network provider,
but may be required for screenings that are ordered at a higher than recommended frequency.
For more information, please call Member Services.

Cardiac (heart) rehabilitation services

The plan covers cardiac rehabilitation services, such as exercise, education, and counseling. The
plan also covers more intensive cardiac rehabilitation programs.
Prior authorization from the plan is required.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 46

Services covered by the plan

Cardiovascular (heart) disease risk-reduction visit (therapy for heart disease)

The plan covers visits with your PCP as part of an effort to help lower your risk for heart disease.
During this visit, your doctor may:

• Discuss aspirin use

• Check your blood pressure
• Give you tips to make sure you are eating right

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

Cardiovascular (heart and blood vessel) disease testing

The plan covers blood tests to check for cardiovascular (heart and blood vessel) and related
disease.
Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

Cervical and vaginal cancer screening

The plan covers pap tests and pelvic exams for women as ordered by a physician or other
licensed health care professional. Pap tests are recommended every 3 years however, plan will
cover based on medical necessity if needed more frequently. Pelvic exams are recommended
annually.
Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 47

Services covered by the plan

Chemotherapy

The plan covers chemotherapy for cancer treatment. Chemotherapy can be administered in your
home, a doctor’s office, or at a hospital inpatient or outpatient facility.
Covered chemotherapy services include:

• Drugs
• Professional services needed to administer the drugs
• Facility fees
• X-ray and lab tests needed for follow-up

Prior authorization from the plan may be required.

For more information, please call Member Services.

Colorectal cancer screening

Members aged 50 years and over are covered for one routine, preventative screening service per
benefit year for the following services:

• Guaiac-based fecal occult blood test

• Fecal immunochemical test
• Screening barium enema
• Flexible sigmoidoscopy
• Screening colonoscopy

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 48

Services covered by the plan

Community health center services

The plan covers services provided by a community health center.

Services include the following:

• Office visits for primary care and behavioral health services

• Obstetric or gynecology (OB/GYN) visits
• Health education
• Medical social services
• Nutrition services, including diabetes self-management training and medical nutrition
therapy
• Tobacco-cessation services
• Vaccines, except for vaccines for travel out of the country

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

Counseling to stop smoking or tobacco use

The plan covers counseling on quitting smoking or tobacco use. (Refer also to “Smoking
cessation” in the Benefits Chart.)

The Tobacco Cessation program provides telephonic education and support services to reduce
the risk of tobacco related health conditions such as high blood pressure, heart disease and
certain cancers by promoting cessation of all tobacco products.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 49

Services covered by the plan

Dental services

The plan does not cover dental services. The services are managed through New Hampshire
Medicaid. For questions about your dental benefits, please contact the NH Medicaid Customer
Service Center. Refer Section 2.8 (How to contact the NH DHHS Customer Service Center) for
contact information and refer to Section 4.4 (NH Medicaid benefits covered outside the plan).

Fluoride varnish services are covered by the plan for some members. Refer to Fluoride varnish
in the Benefits Chart.

For more information, please call Member Services.

Depression screening

The plan covers depression screening for children and adults.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 50

Services covered by the plan

Diabetic supplies and training

The plan covers the following items and services if you have diabetes or pre-diabetes (even if
you do not use insulin):

• Supplies to monitor your blood glucose levels include:

o Blood glucose monitoring device

o Blood glucose test strips
o Lancet devices and lancets
o Glucose-control solutions for checking the accuracy of test strips and monitors

• Fittings for and provision of therapeutic, custom-molded or depth shoes if you have
severe diabetic foot disease.

• The Diabetes education program provides telephonic outreach, education, and support
services to optimize blood glucose, blood pressure and lipid control to minimize the
development and/or progression of diabetic complications.

Prior authorization from the plan may be required if using blood glucose meters and supplies
that are non-preferred products.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 51

Services covered by the plan

Dialysis and other renal (kidney) disease services and supplies

The plan covers the following services:

• Kidney disease education services to teach kidney care and help you make good
decisions about your care
• Outpatient dialysis treatment, including dialysis treatments when you are temporarily out
of the network area, such as when traveling;
• Inpatient dialysis treatments if you are admitted as an inpatient to a hospital or special
care unit
• Self-dialysis training, including training for you and anyone helping you with your home
dialysis treatments
• Home dialysis equipment and supplies
• Certain home support services, such as necessary visits by trained dialysis workers to
check on your home dialysis, to help in emergencies, and to check your dialysis
equipment and water supply

Prior authorization from the plan is not required for services provided by a network provider.
However, prior authorization is required for out-of-network dialysis services.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 52

Services covered by the plan

Durable medical equipment (DME) including replacement parts, modification, repairs,

and training.

The plan covers durable medical equipment (DME) which include items that are:

• Non-disposable and able to withstand repeated use;

• Primarily used to serve a medical purpose for the treatment of an acute or chronic
medically diagnosed health condition, illness, or injury; and
• Not useful to an individual in the absence of an acute or chronic medically diagnosed
health condition, illness, or injury.
• Examples of covered DME include:
o Wheelchairs
o Crutches
o Hospital beds
o Monitoring equipment
o Special beds
o Canes
o Commodes
o Nebulizers
o Oxygen equipment
o IV infusion pumps
o Walkers
o Speech generating devices (augmentative alternative communication (AAC)
devices
o Any other medically necessary DME
• Replacement parts, necessary modifications, and training

Prior authorization may be required for certain equipment.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 53

Services covered by the plan

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services

The plan covers EPSDT services for members under the age of 21 years, including applied
behavioral analysis (ABA) for members with a diagnosis of autism.

The EPSDT benefit is a comprehensive health benefit that helps meet children’s health and
developmental needs. Covered benefits include age-appropriate medical, dental, vision, and
hearing screening services at specified times, commonly referred to as well-child check-ups, and
when health problems arise or are suspected. In addition to screening, EPSDT services include
all medically necessary diagnostic and treatment services to correct or improve a child’s physical
or mental illness or condition. This is particularly important for children with special health care
needs and disabilities.

For specialty treatment services, contact the Special Needs Coordinator at the plan. Call
Member Services and ask for the Special Needs Coordinator during normal business hours as
listed at the bottom of this page.

Prior authorization from the plan is not required for EPSDT screenings. However, some
treatment services do require a prior authorization.

For more information, please contact the Special Needs Coordinator at the plan.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 54

Services covered by the plan

Emergency medical care

The plan covers emergency medical care. A “medical emergency” occurs when you have a
medical condition that anyone with an average knowledge of health and medicine could expect is
so serious that without immediate medical attention, the result may be:

• Serious risk to your health or the health of your unborn child;

• Serious harm to bodily functions;
• Serious dysfunction of any bodily organ or part; or
• In the case of a pregnant woman having contractions:
o There is not enough time to safely transfer you to another hospital before
delivery; or
o The transfer may pose a threat to your health or safety or to that of your unborn
child.

Emergency medical care is covered wherever and whenever you need it, anywhere in the United
States or its territories. Emergency medical care is not covered outside of the United States and
its territories.

If you get emergency medical care at an out-of-network hospital and need inpatient care after
your condition is stabilized you must return to a network hospital for your care to continue to be
covered by the plan. Out-of-network hospital inpatient care is covered if the plan approves your
inpatient stay.

Prior authorization from the plan is not required for in-network and out-of-network emergency
medical care; however, prior authorization is required from the plan for out-of-network hospital
inpatient care after your care is stabilized.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 55

Services covered by the plan

Family planning services

You may choose any New Hampshire Medicaid participating doctor, clinic, community health
center, hospital, pharmacy, or family-planning office in-network or out-of-network. Also, family
planning services do not need a referral.

The following services are covered:

• Family planning exam and medical treatment

• Family planning lab and diagnostic tests
• Family planning methods (birth control pills, patch, ring, IUD, injections or implants)
• Family planning supplies with prescription (condom, sponge, foam, film, diaphragm or
cap)
• Counseling and testing for sexually transmitted infections (STIs), AIDS and other HIV-
related conditions when done as part of an initial, regular, or follow-up family planning
visit
• Treatment for sexually transmitted infections (STIs), including AIDS and other HIV-
related conditions is subject to the requirements described under Physician services in
this Benefits Chart
• Voluntary sterilization. You must be aged 21 years or older, mentally competent and you
must sign a sterilization-consent form. At least 30 days, but not more than 180 days, must
pass between the date that you sign the consent form and the date of the sterilization
procedure.

Prior authorization from the plan is not required.

For more information, please call Member Services.

Fluoride varnish

The plan covers fluoride varnish applied during a doctor/pediatrician visit for a member age 6
months up to age 5 years. Coverage is limited to application of fluoride varnish twice a year.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 56

Services covered by the plan

Gender reassignment surgery

The plan covers gender reassignment services.
Covered services include:
• Mastectomy
• Breast augmentation
• Hysterectomy
• Salpingectomy
• Oophorectomy
• Genital reconstructive surgery

The plan does not cover cosmetic procedures.

Prior authorization from the plan is required.

For more information, please call Member Services.

Habilitation services
The plan covers healthcare services that help children and adults keep, learn or improve skills
and functioning for daily living. These services include occupational, physical and speech
therapies and other services for members with disabilities in a variety of outpatient settings.
Examples include therapy for a child who is not walking or talking at the expected age, and
therapy for an adult for the purpose of maintaining muscle tone.

The plan covers outpatient physical therapy (PT), occupational therapy (OT) and speech therapy
(ST) services limited to 20 visits per benefit year for each type of therapy. Benefit limits are
shared between habilitation services and outpatient rehabilitation services.

Services may be provided in your home, in the therapy provider’s office, in a hospital outpatient
department, or in a rehabilitation facility.

Prior authorization from the plan is required for services exceeding the 20-visit limit.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 57

Services covered by the plan

Hearing services, including hearing aids

The plan covers hearing tests when you get them from a network physician, audiologist, or other
qualified provider.

The plan also covers the following:

• Hearing exams, balance tests, and related consultations

• Evaluations for fitting hearing aids, including ear molds and ear impressions
• Hearing aids, including binaural
• Providing and dispensing hearing aids, batteries, and accessories
• Instruction in the use, care, and management of hearing aids
• Follow-up visit to ensure hearing aid performance
• Loan of a hearing aid when necessary

The hearing aid evaluation exam or a hearing aid consultation is limited to one exam or
consultation every 2 years since the last date of service for members aged 21 years or over, and
as needed for members under age 21 years.

Prior authorization from the plan is not required for hearing exams provided by a network
provider, but may be required for hearing aids, repairs and replacements.

For more information, please call Member Services.

Hepatitis B screening
The plan covers Hepatitis B screening for adolescents and adults when ordered and delivered by
the PCP in an office setting.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 58

Services covered by the plan

Hepatitis C virus (HCV) screening

The plan covers HCV screening for adults who present with one of the following conditions
when ordered and delivered by the PCP in an office setting:

• High risk for Hepatitis C Virus infection, including having had a blood transfusion before
1992; or
• One-time screening for adults born from 1945 through 1965

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

HIV screening
The plan covers HIV screening exams and related tests for adults and adolescents when ordered
and delivered by the PCP in an office setting.

Prior authorization from the plan is not required for services provided by a network provider.
For more information, please call Member Services.

Home health care services

The plan covers services provided by a home health agency including:

• Part-time or intermittent skilled nursing and home health aide services

• Physical therapy, occupational therapy and speech therapy
• Durable medical equipment and supplies

Prior authorization from the plan is required.

For more information, please call Member Services.

Home infusion therapy services

The plan covers home infusion therapy services that include administering nutrients, antibiotics,
and other drugs and fluids by an intravenous (IV) route. Covered services include medically
necessary professional services, medical supplies, and equipment.

Prior authorization from the plan is required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 59

Services covered by the plan

Hospice care
The plan covers hospice care services that are reasonable and necessary to relieve or lessen the
symptoms of the terminal illness, including related conditions or complications. You have the
right to elect hospice if your provider and hospice medical director determine that you are
terminally ill. This means you have a medical condition resulting in a life expectancy of 6
months or less, if the illness runs its normal course.

Covered services include:

• Nursing care
• Medical social services
• Physician services provided by the hospice physician or the member’s PCP
• Counseling services, including dietary counseling
• General inpatient care for pain control or symptom management which cannot be
provided in an outpatient setting
• Inpatient respite care for members not residing in a nursing facility
• Durable medical equipment and supplies for self-help and personal comfort related to
relieving, lessening, or managing the symptoms and effects of the member’s terminal
illness or conditions related to the terminal illness
• Drugs to relieve, lessen, or manage the symptoms or effects of the member’s terminal
illness or conditions related to the terminal illness
• Home health aide and homemaker services
• Physical therapy, occupational therapy, and speech language pathology services for the
purpose of symptom control or to enable the member to maintain the ability to perform
activities of daily living and basic functional skills
• Ambulance and wheelchair van transportation
• Any other service that is specified in the member’s plan of care as reasonable and
necessary to relieve, lessen, or manage the member’s terminal illness and related
conditions

Prior authorization from the plan is required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 60

Services covered by the plan

Hysterectomy
The plan covers a hysterectomy, which is the surgical removal of the uterus (womb). The plan
does not cover hysterectomy procedures when performed solely for the purpose of sterilization.

In accordance with federal regulations, a hysterectomy consent form must be signed and must
include written acknowledgment that you were informed both orally and in writing that the
hysterectomy would make you permanently incapable of reproducing.

Prior authorization from the plan is required.

For more information, please call Member Services.

Immunizations
The plan covers certain vaccines (age restrictions may apply), including:

• Pneumonia (pneumococcal) vaccine

• Flu (influenza) shots
• Hepatitis B vaccine, if you are at high or intermediate risk of getting Hepatitis B
• Childhood/adolescent immunizations
• Shingles (Herpes zoster) vaccine
• Human papilloma virus (HPV)

Immunization coverage does not include vaccines required or recommended for out of country
travel.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

Infertility services
The plan covers infertility services limited to determining the cause and treatment of medical
condition(s) causing infertility.

Prior authorization from the plan may be required..

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 61

Services covered by the plan

Inpatient hospital services, including acute rehabilitation services

The plan covers inpatient hospital services, including:
• Semi-private room (or a private room if it is medically necessary)
• Meals, including special diets
• Nursing services
• Costs of special care units, such as intensive care or coronary care units
• Drug and medications
• Lab tests
• X-ray and other radiology services
• Surgical and medical supplies
• Durable medical equipment, such as wheelchairs
• Operating and recovery room services
• Physical, occupational, and speech therapy
• Administration of blood products
• Physicians services, including anesthesia
Prior authorization from the plan is required except for emergency admissions.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 62

Services covered by the plan

Inpatient mental health services

The plan covers inpatient mental health services that include:

• Inpatient mental health services to evaluate and treat an acute psychiatric condition*
• Psychiatric consultation on an inpatient medical unit*

*Special coverage rules apply for some inpatient stays. If you are age 21-64 years, contact
Member Services to see if you meet coverage requirements.

There is no lifetime limit on the number of days a member can have in an inpatient mental health
care facility.

Refer also to Outpatient mental health services in this Benefits Chart.

Refer also to Substance use disorder (SUD) treatment services in this Benefits Chart.

Prior authorization from the plan is required except for residential substance use disorder and
emergency admissions.

For more information, please call Member Services.

Laboratory services
The plan covers laboratory services when ordered by a physician or other health care practitioner
licensed to do so and provided by a network laboratory.

Prior authorization may be required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 63

Services covered by the plan

Maternity services
The plan covers pre-natal, delivery, nursery, and postpartum maternity services. Delivery is
covered in a hospital and birthing center (whether in the birthing center or as a home birth when
attended by birthing center staff), and in your home. Any required laboratory and ultrasound
services are also covered.

Additional maternity related services are also available through the Home Visiting NH and
Comprehensive Family Support Services programs. For information about these programs,
please call the NH Division of Public Health Services toll-free at 1-800-852-3345, ext. 4501
(TDD Access Relay: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:30 p.m. ET.

Prior authorization from the plan is not required for services provided by network providers.

For more information, please call Member Services.

Medical supplies
The plan covers medical supplies. Medical supplies are consumable or disposable items that are
appropriate for relief or treatment of a specific medically diagnosed health condition, illness, or
injury.

Medical supplies include the following:

• Ostomy supplies
• Catheters
• Incontinence products
• Splints
• Tracheotomy supplies

Prior authorization from the plan may be required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 64

Services covered by the plan

Medical nutrition therapy

Coverage is provided for medically necessary Medical Nutrition Therapy when provided as a
part of EPSDT services for Members who are age 21 and under when furnished by a registered
dietician and prescribed by a physician. Coverage for Medical Nutrition Services includes (but is
not limited to):

• Scientific evaluation of your diet;

• Suggestions for diet modification;
• Nutritional screening;
• Preventive or therapeutic dietary therapy

Services must be rendered by a registered dietician and prescribed by a physician that is

participating with NH Healthy Families, unless authorized in advance.

Prior authorization is not required for Medical Nutritional Services when provided as part of
EPSDT services for Members age 21 and under. Prior authorization is not required for
Nutritional Services when provided as part of extended services offered to pregnant women,
regardless of age.

For more information, please call Member Services

Mental health services

Refer to Inpatient mental health services in this Benefits Chart.
Refer to Outpatient mental health services in this Benefits Chart.
Refer to Substance use disorder (SUD) treatment services in this Benefits Chart.

Obesity screening and therapy for weight loss

The plan covers obesity screening and counseling therapy to help you lose weight. Talk to your
doctor to find out more.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

Occupational therapy services

Refer to Outpatient rehabilitation services (physical therapy, occupational therapy, speech and
language therapy services) in this Benefits Chart.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 65

Services covered by the plan

Organ and tissue transplants

The plan covers the following organ and tissue transplants:

• Kidney transplants
• Heart transplants
• Heart and lung transplants
• Lung transplants
• Bone marrow
• Stem cell
• Liver transplants
• Pancreas transplants
• Pancreas and kidney transplants
• Cornea transplants
• Skin transplants except for hair transplants
• Bone grafts

If you need a transplant, a plan approved transplant center will review your case to determine
your status as a candidate for a transplant.

Prior authorization from the plan is required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 66

Services covered by the plan

Orthotic devices
The plan covers orthotic devices, which are orthopedic items applied externally to a limb or body
to:

• Protect against injury

• Support a weak or deformed portion of the body; or
• Prevent or correct a physical deformity or malfunction.

Orthotic devices include:

• Scoliosis spinal braces

• Leg braces
• Hand and foot orthotics

Prior authorization from the plan is required.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 67

Services covered by the plan

Outpatient mental health services

The plan covers outpatient mental health services provided by a community mental health center,
psychiatrist, psychiatric advance practice registered nurse (APRN), mental health therapy
provider, psychologist, licensed psychotherapy provider, community health center, federally
qualified health center (FQHC), rural health center (RHC), and outpatient mental health
facilities.

Covered services include:

• Medication visits
• Individual, group and family therapy
• Diagnostic evaluations
• Partial hospitalization program (PHP)*
• Intensive outpatient program (IOP)*
• Emergency psychiatric services
• Electroconvulsive therapy (ECT)*
• Transcranial magnetic stimulation*
• Crisis intervention
• Individualized Resiliency and Recovery Oriented Services (IROS)
• Case Management services, including Assertive Community Treatment (ACT)
• Psychological testing*

*Prior Authorization from the plan is not required except for those services indicated with an
asterisk.

Refer also to Inpatient mental health services in this Benefits Chart.

Refer also to Substance use disorder (SUD) treatment services in this Benefits Chart.

For more information, please call Member Services

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 68

Services covered by the plan

Outpatient hospital services

The plan covers outpatient hospital services for the diagnosis or treatment of an illness or injury.

Covered services include:

• Services in an emergency department or outpatient clinic, including observation stays or

outpatient surgery
• Labs and diagnostic tests provided by the hospital
• X-rays and other radiology services provided by the hospital
• Radiation therapy, including technician services, materials, and supplies
• Some screening and preventive services
• Some drugs that you cannot administer yourself
• Surgical supplies, such as dressings
• Casting materials
• Administration of blood products
• Intravenous (IV) infusions

Prior authorization from the plan is required for some services, including outpatient surgery and
some diagnostic tests.

See the specific service in this Benefits Chart for more information or please call Member
Services.

Outpatient rehabilitation services (physical therapy, occupational therapy, speech and

language therapy services)

The plan covers rehabilitation services to help you recover from an illness, accident, or surgery.
Rehabilitation services include physical therapy, occupational therapy, and speech language
therapy.

Coverage is limited to 20 visits per benefit year for each type of therapy. Benefit limits are
shared between outpatient rehabilitation and habilitation services. Services may be provided in
your home, in the therapy provider’s office, in a hospital outpatient department, or in a
rehabilitation facility.

Prior authorization from the plan is required for services exceeding the 20-visit limit.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 69

Services covered by the plan

Outpatient surgery
The plan covers outpatient surgery and services in network hospital outpatient facilities and
network ambulatory surgical centers.

Prior authorization may be required for certain procedures.

For more information, please call Member Services.

Oxygen and respiratory therapy equipment

The plan covers oxygen equipment, including oxygen systems, oxygen refills, and oxygen
therapy equipment rentals.

The plan also covers respiratory equipment, including CPAP machines, BiPAP machines, and
ventilators.

Prior authorization from the plan is not required for oxygen provided by a network provider.
Prior authorization from the plan may be required for respiratory therapy equipment.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 70

Services covered by the plan

Personal care attendant services

The plan covers personal care attendant services to assist with activities of daily living and
instrumental activities of daily living. To be eligible for this service, you must be age 18 years or
older, wheelchair bound, and able to self-direct your care.

Services include assistance with:

• Bathing and other personal hygiene activities

• Dressing and grooming
• Medication administration and management
• Mobility and transfers
• Toileting and related tasks
• Meal preparation and eating
• Laundry
• Light housekeeping

Prior authorization from the plan is required.

For more information, please call Member Services.

Physical therapy services

Refer to Outpatient rehabilitation services (physical therapy, occupational therapy, speech and
language therapy services) in this Benefits Chart.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 71

Services covered by the plan

Physician, physician assistant, and advance practice registered nurse services

The plan covers physician, physician assistant, and advance practice registered nurse services,
including

• Diagnosis and treatment services, preventive services and surgical services, (including
anesthesia), which are provided in an office or other outpatient setting, nursing facility, or
your home:
• Consultation, diagnosis, and treatment by a specialist, including an obstetrician or
gynecologist (OB/GYN), either face-to-face or via telemedicine services
• Second opinion by an in-network provider or an out-of-network provider (with prior
authorization), for example, before medical or surgical procedure is performed
• Inpatient hospital visits for acute care days of stay
• Laboratory and radiology services
• Temporomandibular joint (TMJ) evaluation and treatment
• Pain management
• Anesthesia as part of a child’s dental treatment plan

See also specific services for additional coverage by the plan.

Prior authorization from the plan is not required for services provided by a network provider,
except for certified ambulatory surgical centers, outpatient surgery and some pain management
centers.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 72

Services covered by the plan

Podiatry services
The plan covers routine and specialty foot care for pathological conditions of the foot due to
localized illness, injury or symptoms involving the foot.

Services include:

• Routine foot care burring and trimming of nails when your PCP determines your need for
the service and provides you with a referral to a podiatrist
• Prevention and reduction of corns, calluses, and warts by cutting or surgical means
• Casting, strapping, and taping when performed by a podiatrist for the treatment of
fractures, dislocations, sprains, strains, and open wounds of the ankle, foot, and toes

Service limits for routine and non-routine services do not apply.

For more information, please call Member Services.

Prescription drugs
Prescription Drugs (and over the counter drugs with a prescription)
Retail Pharmacy Copayment
• $1 copayment – up to a 30-day supply
• $2 copayment for each non-preferred prescription drug (if the prescribing provider
determines that a preferred drug will be less effective and/or will have adverse effects for
the member, the non-preferred drug will be $1.00)

Mail Order Copayment (only certain drugs available through mail order)
• $1 copayment for a 90-day supply
• $0 copayment for family planning products or for Clozaril® (Clozapine) prescriptions or
tobacco cessation products.

For information on prescription drug coverage, refer to Chapter 7 (Getting covered prescription
drugs).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 73

Services covered by the plan

Private duty nursing services

The plan covers private duty nursing services provided by a registered nurse (RN) or licensed
practical nurse (LPN). Members eligible for these services require continual skilled nursing
observation, judgment, assessment, or interventions for more than a 2-hour duration to maintain
or improve the member’s health status.

The first step in the approval process is a written order from a physician or advanced practice
registered nurse, including a written plan of care, that describes why private duty nursing
services are medically necessary for the member. Supporting documentation demonstrating the
care skill level and continuous needs of the member must be provided by the agency delivering
private duty nursing services.

Prior authorization from the plan is required.

For more information, please call Member Services.

Prostate cancer screening

The plan covers the following prostate cancer screening as part of a medical exam or as needed:

• A digital rectal exam

• A prostate specific antigen (PSA) test

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 74

Services covered by the plan

Prosthetic devices and related supplies

The plan covers the purchase and repair of prosthetic devices and related supplies. Prosthetic
devices are non-dental, artificial types of replacement, corrective or supportive devices or parts
of a device that are used to replace a missing portion of the body, or to replace a missing function
of the body.

Covered prosthetic devices and related supplies include:

• Prosthetic shoes
• Artificial arms and legs
• Breast prostheses (including a surgical brassiere) after a mastectomy
• Artificial larynxes

Prior authorization from the plan may be required.

For more information, please call Member Services.

Pulmonary rehabilitation services

The plan covers pulmonary rehabilitation services for members who have moderate-to-severe
chronic obstructive pulmonary disease (COPD). Covered services include training on breathing
techniques, medications, nutrition, relaxation, oxygen, travel, and how to do everyday tasks with
less shortness of breath, as well as how to stay healthy and prevent worsening of COPD
symptoms.

Prior authorization from the plan is not required.

For more information, please call Member Services.

Screening for lung cancer with low dose computed tomography (LDCT)
The plan covers LDCT services once every 12 months for people aged 55 to 80 years who have a
30 pack-year smoking history and currently smoke or have quit within the past 15 years.
Screening should be discontinued once a person has not smoked for 15 years or develops a health
problem that substantially limits life expectancy or the ability or willingness to have curative
lung surgery.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 75

Services covered by the plan

Sexually transmitted infection (STI) screening and counseling

In addition to screening for HIV and Hepatitis B (discussed separately in this Benefits Chart), the
plan covers screenings for chlamydia, gonorrhea, and syphilis. The plan also covers related
intensive behavioral counseling sessions.

Prior authorization from the plan is not required for services provided by a network provider.

For more information, please call Member Services.

Smoking cessation
The Tobacco Cessation program provides telephonic education and support services to reduce
the risk of tobacco related health conditions such as high blood pressure, heart disease and
certain cancers by promoting cessation of all tobacco products.

The plan covers medications to aid the cessation of smoking including nicotine patches, gums,
lozenges and Chantrix (for which specific limits apply).

For more information, please call Member Services.

Speech and language pathology services)

Refer to Outpatient rehabilitation services (physical therapy, occupational therapy, speech and
language therapy services) in this Benefits Chart.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 76

Services covered by the plan

Substance use disorder (SUD) treatment services

The plan covers substance use disorder treatment services provided by a community mental
health center, community health center, federally qualified health center (FQHC), rural health
center (RHC), mental health provider, acute care hospital, psychiatric hospital, masters licensed
alcohol and drug counselor (MLDAC), licensed alcohol drug counselor (LADC), psychiatrist,
psychiatric advance practice registered nurse (APRN), physician, certified recovery support
worker, residential treatment and rehabilitation facilities, methadone clinics/opioid treatment
programs, and peer recovery programs.
Covered services may include:

• Screening, brief intervention, and referral to treatment (SBIRT)

• Substance use screenings
• Individual, group, and family therapy
• Intensive outpatient substance use disorder services
• Partial hospitalization program (PHP)
• Medically monitored outpatient withdrawal management
• Crisis intervention
• Peer recovery support
• Non-peer recovery support
• Continuous recovery monitoring
• Opioid treatment services
• Medication assisted treatment
• Medically monitored residential withdrawal management
• Residential treatment services, including specialty services for pregnant and postpartum
women

Refer also to Inpatient mental health services in this Benefits Chart.

Refer also to Outpatient mental health services in this Benefits Chart.
Special coverage rules apply for some inpatient stays. If you are age 21 – 64 years, contact
Member Services to see if you meet inpatient coverage requirements.
Prior authorization may be required.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 77

Services covered by the plan

Telemedicine services
The plan covers audio and video interactive telemedicine services for Medicaid-covered services
(excluding primary care services) when services are delivered by the following providers as a
method of delivery of medical care:

• Physician or Physician Assistant

• Advance Practice Registered Nurse (APRN) or Clinical Nurse Specialist
• Nurse Midwife
• Clinical Psychologist
• Clinical Social Worker
• <Insert as applicable: Registered Dietitian>

Eligible sites where video interactive telemedicine services may be delivered are:

• Medical practitioner’s offices

• Hospitals
• Skilled nursing facilities
• Community Mental Health Centers
• Federally Qualified Health Centers (FQHC)
• Rural Health Centers (RHC)

Transportation services – Ambulance transportation

Refer to Ambulance services – Emergency in this Benefits Chart.

Refer to Ambulance services – Non-emergency in this Benefits Chart.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 78

Services covered by the plan

Transportation services – Non-emergency medical transportation (NEMT)

The plan covers non-emergency medical transportation services if you are unable to pay for the
cost of transportation to provider offices and facilities for medically necessary New Hampshire
Medicaid covered services listed in the Benefits Chart in Chapter 4. For authorized non-
emergency medical transportation, you must follow plan rules for transportation coordination
and reimbursement.

• Enroll in the Friends and Family Mileage Reimbursement Program: Get reimbursement
for mileage from your home to your Medicaid-covered healthcare service, then back to
your home. Drive yourself or have a friend or family member drive you to the
appointment. A Medicaid Transportation Reimbursement Form must be completed for
each approved trip.

• Request a ride: Members who do not have a vehicle or a friend or family member who
can drive them can request a ride by calling the plan’s transportation broker who will
arrange the ride using public transportation, a transportation service, a wheelchair van
service, or non-emergency ambulance service. Please call at least 48 hours in advance to
request a ride.

Services are managed by Coordinated Transportation Solutions (CTS). They can be reached by
calling 1-877-671-6291.
Prior authorization may be required.
For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 79

Services covered by the plan

Urgently needed care

The plan covers urgently needed care whether from an in-network or out-of-network provider
when network providers are unavailable.

Urgently needed care is care given to treat the following:

• A non-emergency (does not include routine primary care services)

• A sudden medical illness
• An injury
• A condition that needs care right away
For more information, refer to Section 3.6 (Emergency, urgent, and after-hours care).
If you require urgently needed care, you should first try to get it from a network urgent care
center or call the plan’s 24/7 Nurse Advice Call Line at 1-866-769-3085. You should inform
your PCP whenever possible if you have received such care.

Prior authorization from the plan is not required for urgently needed services.

Urgently needed care is not covered outside of the United States and its territories.

For more information, please call Member Services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 80

Services covered by the plan

Vision services and eyewear

The plan covers the following services:

• Eye care services by an ophthalmologist, optometrist or optician

• One (1) refraction eye exam to determine the need for eyeglasses no more frequently than
every 12 months.

• Eye exams to diagnose and monitor medical conditions of the eye

• One pair of single vision lenses with frames, as follows:
o For members 21 years of age and older, if the refractive error is at least plus or
minus .50 diopter, according to the refractive error which may be calculated as a
combined total of the spherical and cylindrical errors, in both eyes
o For members under 21 years of age, if the refractive error is at least plus or minus
.50 diopter, according to the refractive error which may be calculated as a
combined total of the spherical and cylindrical errors, in at least one eye
• One pair of eyeglasses with bifocal corrective lenses (or one pair of eyeglasses with
corrective lenses for close vision and one pair of eyeglasses with corrective lenses for
distant vision) if there is a refractive error of at least .50 diopter for both close and distant
vision
• Transition lenses for members with ocular albinism
• Contact lenses for ocular pathology in cases where the visual acuity is not correctable to
20/70 or better without contact lenses, or when required to correct aphakia or to treat
corneal disease
• Replacement of the component eyeglasses parts due to breakage or damage, subject to all
of the following:
o Replacements may be in the form of a single lens, both lenses, frame only, or a
complete pair of corrective lenses
o Each component part or complete pair of corrective lenses may only be replaced
one time within a 12-month period
o When the member has two (2) pairs of eyeglasses in lieu of bifocals, each pair of
eyeglasses is eligible for replacement
• Only one replacement of lost eyeglasses per lifetime for members under age 21 years

Continued on the next page

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 81

Services covered by the plan

Vision services and eyewear – Continued from the previous page

The plan covers the following services:

• Trifocal lenses if the member:

o Is employed and the trifocal lenses are required for the work involved in the
member’s employment; or
o Is a full time student and the trifocal lenses are required for the work involved in
the member’s education; or
o Currently has trifocals.
• Replacement of nickel frames after 12 months, if the member has a documented allergy
to nickel demonstrated by skin irritation and wearing down of the frame in the affected
area
• Ocular prostheses, including artificial eyes and lenses

Prior authorization from the plan is not required for covered services provided by network
providers.
For more information, please call Member Services.

X-rays and radiology services

The plan covers radiation therapy and diagnostic X-rays.

Prior authorization from the plan is required for high-tech diagnostic imaging, including CT
scans, MRIs, MRAs, PET scans, and nuclear cardiac imaging, unless part of an emergency room
visit, an inpatient hospitalization, or provided at the same time with, or on the same day as, an
urgent care facility visit.
For more information, please call Member Services.

Section 4.3 Extra benefits provided by the plan

Our plan offers some extra benefits. NH Healthy Families has programs and services that add
value to your covered services. We are always looking for ways to help you stay healthy or
improve your health. Check our website at [Link] for the most up-to-date
list of value added benefits or call Member Services for more information.

Extra benefits include:

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 82

Programs and Services Details

• $30 incentive payment for each:
My Health Pays
o Annual Flu Shot or Flu Mist Vaccine - ages 6
Rewards for completing months and up
healthy behaviors. o Annual Breast Cancer Screening (mammogram)
- women ages 40-74
o Annual Prostate Exam/Prostate Cancer
Screening– men ages 50 and up

o Completion of Tobacco Cessation Program –

complete 6 health coaching sessions – ages 18 and
up

o Complete Annual Health Needs Assessment

o 6 Infant Well Care visits by 15 months old

o Annual Well Care Visit (one per calendar year/
ages 2+)
• $20 incentive payment
o Annual Comprehensive diabetes care
• $10 incentive payment:
o Every 3rd prenatal doctor visit.* ($30 maximum.)
o Postpartum doctor visit between 21 – 56 days
after delivery.

* You must notify NH Healthy Families of your pregnancy by

calling us or submitting a completed Notification of Pregnancy
(NOP) form. The form can be found on the website at
[Link].

Note, the prenatal visit count begins after you notify us you are
pregnant.
• Aims to reduce pregnancy complications, premature
Start Smart for Your Baby deliveries, low birth weight, and other poor birth
– A program designed to outcomes in babies.
support pregnant members. • Start Smart for Baby Packet and Thermometer

• Start Smart Baby Shower Program

• Start Smart for Your Baby Texting Program
• Electric Breast Pumps available

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 83

Programs and Services Details

24-Hour Nurse Advice Line •Medical advice

Free health information staffed by •Answers to questions about your health
nurses available 24/7. •Advice about an injury or illness
•Answers questions about going to ER or Urgent
Care
Your one-on-one coaching sessions support you as
you manage your health conditions such as:

Disease Management – Services o Asthma (adult and pediatric)

geared toward helping you improve o Back Pain
your health through a personal o COPD
health coach. o Diabetes (adult and pediatric)
o Heart Disease (heart failure and CAD)
o Hypertension/Hyperlipidemia
o Depression

MemberConnections representatives help you to:

MemberConnections® – Program to
promote preventive health and  Find a doctor in your area
connect high-risk members to
healthcare and community social  Assist with access to care concerns
services.  Navigate health plan benefits
 And even check on you at home, if necessary

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 84

VALUE ADDED BENEFITS CONTINUED.

Programs and Services Details

Gives 24/7 access to:

ConnectionsPLUS® – Program that
provides free cell phone to members • Our staff
who do not have safe and reliable • Your providers
access to a phone. • Telehealth services
• 911

Fluvention Free flu shots every year for members 6 months and older.

Interpreter Services Telephonic or face-to-face services covered free of charge.

Puff-Free Pregnancy Special tobacco-cessation program for pregnant women.

Use the credit to buy glasses with:

Vision Enhancement- Choose to
get a credit and select frames outside • Single vision lenses
of the standard selection.
• Bifocal or trifocal lenses

Health coaches offer telephonic education and support to

Smoking Cessation –Health Coaches
help you quit smoking. A special program is available to
available to help members quit
assist pregnant members to quit smoking (Puff Free
smoking.
Pregnancy).

All health plan Members have free access to their

account information and helpful tools 24 hours per day /
7 days per week through the Secure Member Portal.
Once the Member enrolls and becomes active with
NHHF, they can create an account online where they are
Secure Member Portal
able to update their PCP, send a secure e-mail to a
health plan representative, complete their annual Health
Needs Assessment, view their benefit summary, etc.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 85

Section 4.4 NH Medicaid benefits covered outside the plan

New Hampshire Medicaid directly covers some Medicaid benefits that the plan does not
cover even though the plan may help coordinate them. That is why you should always
carry both your NH Healthy Families and New Hampshire Medicaid membership cards.
Always show your NH Healthy Families membership card to receive services covered by
the plan. If you need help getting any covered services, please call Member Services
(phone numbers are printed on the back cover of this handbook).

ALWAYS CARRY BOTH YOUR NH HEALTHY FAMILIES AND NEW

HAMPSHIRE MEDICAID MEMBERSHIP CARDS.

The following services are not covered by our plan. However, these services are available
through New Hampshire Medicaid as long as the provider is enrolled with New
Hampshire Medicaid:

• Some prescription drugs are covered by New Hampshire Medicaid when billed
through a pharmacy. They include certain prescription drugs related to Hepatitis C
and Hemophilia, and prescription drugs Carbaglu® and Ravicti®.

• Comprehensive dental services, including orthodontia, for members under age 21

years

• Dental services limited to the treatment of acute pain or infections for members
aged 21 years and over

• Early supports and services (early intervention services) for infants and children
aged birth to 3 years

• Medicaid-to-school services

• Nursing home or nursing facility services, including: skilled nursing facility

services, long-term care nursing facility services, and intermediate care facility
services (nursing homes and acute care swing beds)Nursing home or nursing
facility services (sometimes called long-term care nursing facility services)

• Intermediate care facility services (nursing home and acute care swing beds)

• Glencliff Home services

• Division of Child, Youth, and Family Program services for Medicaid eligible
children and youth referred by the courts or juvenile parole board, including:

o Home based therapy

o Child support services (also known as Child Health Support Services)

o Intensive Home and Community Services

NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 86

o Placement services

o Private Non-medical Institutional Care for Children

o Crisis intervention

• Home and Community-Based Care long-term services and supports for:

o Members with acquired brain disorders;

o Members with developmental disabilities;

o Members up to age 21 years with developmental disabilities under the In-

Home Supports waiver program; and

o Members with age-related disabilities, chronic illnesses, or physical

disabilities under the Choices for Independence program.

These programs provide long-term services and supports in your home, as well as
in assisted living facilities, community residences, and residential care homes.
For more information, please call NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-
844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to
4:00 p.m. ET.

Section 4.5 Benefits not covered by our plan or New Hampshire

Medicaid
This section tells you what benefits are excluded by the plan. “Excluded” means that the plan
does not pay for these benefits. The list below describes some services and items that are not
covered by the plan.

The plan will not cover the services and items listed in this section (or anywhere else in
this Member Handbook) except under the specific conditions listed. If you think that we
should pay for a service or item that is not covered, you may file an appeal or grievance.
For information about filing an appeal or grievance, refer to Section 10 (What to do if you
want to appeal a plan decision or “action”, or file a grievance).

The following services and supplies are not covered. This may not be an all-inclusive
list. If a service is on the “List of Non-Covered Services” that means both NH Healthy
Families and NH Medicaid do not pay for these services. Remember, if you seek care for
any “Non-Covered” service, you will be responsible for payment of any changes.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 87

List of Non- Covered Services

Abortions (Voluntary) - Some abortions are covered in limited circumstances.

Alternative Medicine - Acupuncture and Biofeedback, etc.

Cosmetic or Plastic Surgery

Experimental Procedures, Drugs and Equipment

Personal Comfort Items

Non-Medical Equipment

Physical Exams Required for Employment, Insurance or Licensing

Radial Keratotomy

Services Not Allowed by Federal or State Law.

Weight Reduction and Control Services - This includes, weight loss drugs or products,
gym memberships or equipment for the purpose of weight reduction.

Service and Therapy Animals

Services Provided Outside the US and its Territories including Vaccinations for Out of
Country Travel

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 88

Chapter 5. Using NH Healthy Families to help manage your health

Section 5.1 Staying healthy

NH Healthy Families has many options to help you get and stay healthy. We believe in treating
the whole person and throughout this handbook you will find programs that reinforce this
practice. Some of the programs listed in Section 4.3 (Extra benefits) can help improve your
quality of life as well.

NH Healthy Families also wants to make sure you get supportive services to ensure that your
care is effective. Habilitative and Rehabilitative services are part of your covered benefits (see
Chapter 4) along with support for your children’s and your own preventive care needs.

Quality Improvement Program

NH Healthy Families’ Quality Improvement program is committed to providing quality
healthcare for you and your family. We want to help you improve and maintain your health. Our
program follows the National Committee on Quality Assurance (NCQA) standards and helps
promote safe, reliable, and quality healthcare. NH Healthy Families adopts and uses evidence-
based preventive and clinical practice guidelines for medical and Behavioral Health care which
are reviewed and approved on an annual basis or when changes are needed by our Quality
Improvement Committee.

To help promote safe, reliable, and quality healthcare, we:

• Conduct a detailed check on providers when they join our provider network.
• Monitor our network to make sure you have access to all types of healthcare services.
• Offer education and programs about your general healthcare and specific diseases.
• Remind you to see your doctor for well visits and get preventive tests.
• Investigate your concerns about healthcare services you received.

NH Healthy Families believes your input can help improve our services. We send out a member
survey each year asking you questions about your experience with health care and the services
you are receiving. If you receive a survey, we hope you will take the time to send us your
answers. For more information on the QI Program, please visit our website at
[Link].

If you have a concern about your care or any service we provided, please contact us at 1-866-
769-3085.

NH Healthy Families provides primary and secondary preventive care services, rated A or B, in
accordance with the recommendations of the U.S. Preventive Services Task Force. For children,
we also provide preventive services recommended by the American Academy of Pediatrics
Bright Futures Program.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 89

Section 5.2 Care coordination support

NH Healthy Families understands you may need assistance navigating the healthcare system. We
offer care management services to assist with scheduling appointments, arranging for
transportation, housing and connecting you with community resources such as food stamps,
utilities and support groups.

These services are available if you:

• have social and care coordination needs
• have complex medical health needs
• have behavioral health needs
• are pregnant
• have a disability

Our care managers are registered nurses, behavioral health clinicians or social workers. They
help our members understand major health problems and assist in arranging members’ health
care needs. Care Managers work with members and their doctors to help identify barriers and
support the provider’s plan of care.

Members enrolled in care management often see several doctors. They may need medical
supplies or help at home. NH Healthy Families’ care managers can assist members in
coordinating aspects of their care. Members enrolled in care management often have complex
conditions such as Sickle, Cell, Multiple Sclerosis, Kidney or Renal Disease, Organ Transplants,
Cancer, Hemophilia and/or Depression.

In addition to Care Managers, NH Healthy Families has a Special Needs Coordinator who can
help you enroll in the care management program and connect you with healthcare and
community based resources. If you have one or more of the following conditions, we invite you
to contact our Special Needs Coordinator or any member of our Care Management team:

• Chronic illness such as asthma, diabetes, heart failure, chronic obstructive

pulmonary disease(COPD)
• Mental illness
• HIV/AIDS
• Foster care needs or receiving services the Department of Child, Youth and
Families (DCYF)
• Homeless

If you have special healthcare needs, NH Healthy Families is here for you. To enroll in our Care
Management Program please call 1-866-769-3085 (TDD/TTY 1-855-742-0123 Relay 711) and
request care management services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 90

Section 5.3 Continuity of care

“Continuity of care” refers to continuing your care coverage through your transitions between
plans, health care settings, or other treatment settings.

For example, transitions occur when:

o You change from the New Hampshire Medicaid Fee-for-Service program which contracts
directly with providers to a New Hampshire Medicaid managed care plan, such as NH
Healthy Families.

o You change from treatment provided by a New Hampshire Medicaid Fee-for-Service

provider to a Medicaid managed care plan network provider.

o You change from one New Hampshire Medicaid managed care plan to another.

o You move from a nursing facility to home and you continue to need some or all of the
care you received in the nursing facility.

When you transfer to another provider or plan, you or your authorized provider may request
transfer of your medical records to your new provider(s).

If, at the time you enroll in NH Healthy Families, you are transferring from:

• New Hampshire Medicaid’s Fee-For-Service program—You can continue to get services,

including prescription drugs, for which you received written prior authorization for up to
60 calendar days. This occurs only after your initial enrollment effective date with NH
Healthy Families, or until completion of a medical necessity review by the plan,
whichever comes first.

• Another New Hampshire Medicaid managed care plan—You can continue to get services
for which you received written prior authorization for up to 15 calendar days or until the
expiration of the issued prior authorization(s), whichever comes first.

Note: If you have a prescription that was authorized prior to your enrollment with the
plan and you have one or more refills remaining, your pharmacist may be able to transfer
your prescription refill(s) to our plan if the drug does not require prior authorization. For
more information, contact Member Services (phone numbers are printed on the back
cover of this handbook).

If you transfer from NH Healthy Families to another New Hampshire Medicaid managed care
plan:

• Your NH Healthy Families benefits end on the effective date of enrollment in your new
plan.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 91

• The plan or other payer responsible for your coverage at the time of your inpatient
admission is fully responsible for your inpatient care and all related services authorized
while you were an inpatient until the day of your discharge from the hospital.

• Your new New Hampshire Medicaid managed care plan must honor a prior authorization
in place by NH Healthy Families for 15 calendar days, or until the prior authorization
expires, whichever comes first. If you need to continue the service or drug beyond the
prior authorization expiration date, contact your new health plan to request continuation
of benefits.

Continuity of care after discharge

When you are discharged from inpatient, nursing facility, or institutional care for physical or
behavioral health disorders, or discharged from a substance use disorder treatment program,
transitional care shall be:

• Readily available and delivered in accordance with your discharge plan, or as order by
your primary care or specialty care provider.

• Clinical assessment and care planning from a primary or specialty provider shall be
available within seven (7) calendar days of discharge.

• Home care shall be available with a home care nurse or a licensed counselor within two
(2) calendar days of discharge, if ordered by your primary care or specialty care provider
or as part of your discharge plan.

When discharged from NH Hospital, NH Healthy Families will ensure:

• An appointment with a community mental health program or other appropriate mental

health clinician is scheduled for you within seven (7) calendar days after discharge;

• If you are a new Community Mental Health Center client, an intake appointment is
scheduled for you within seven (7) calendar days; and

• Homeless members shall be discharged to an appropriate living situation.

Continuity of care for pregnancy

If, at the time of enrollment into NH Healthy Families, you are transferring from the New
Hampshire Medicaid Fee-for-Service program or another Medicaid managed care health plan,
and are currently receiving services from provider who is not in the NH Healthy Families
network:

• If in your first trimester of your pregnancy at the time of your enrollment in NH Healthy
Families, you may continue your covered prenatal services with your out-of-network
provider, as applicable, until NH Healthy Families can transfer you to a network
provider. The transfer will only occur when it will not be harmful to your health; or
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 92

• If in your second or third trimester of pregnancy at the time of your enrollment in NH

Healthy Families, you may continue your covered prenatal care services with your out-
of-network provider, as applicable, through the postpartum period. (Postpartum or after
delivery care includes the first postpartum visit, any additional visits necessary to manage
any complications related to delivery, and medical record documentation.)
For more information, contact Member Services (phone numbers are printed on the back cover
of this handbook).

Section 5.4 Mental health parity assurance

Federal and state laws require the plan to provide coverage for mental health and substance use
disorder treatments as favorably as it provides coverage for other medical health services. This is
referred to as parity. Parity laws require coverage for mental health and/or substance use
disorders be no more restrictive than coverage for other medical conditions, such as diabetes or
heart disease. For example, if the plan provides unlimited coverage for physician visits for
diabetes, it must do the same for depression or schizophrenia.

Parity means that:

• NH Healthy Families must provide the same level of benefits for any mental health
and/or substance use disorder as it would for other medical conditions you may have;

• NH Healthy Families must have similar prior authorization requirements and treatment
limitations for mental health and substance use disorder benefits as it does for other
medical benefits;

• NH Healthy Families must provide you or your provider with the medical necessity
criteria used by NH Healthy Families for prior authorization upon either your request or
your provider’s request;

• NH Healthy Families must not impose aggregate lifetime or annual dollar limits on
mental health or substance use disorder benefits;

• Within a reasonable time frame, NH Healthy Families must provide you the reason for
any denial of authorization for mental health and/or substance use disorder services; and

• If NH Healthy Families provides out-of-network coverage for other medical benefits, it

must provide comparable out-of-network coverage for mental health and/or substance use
disorder benefits.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 93

The parity requirement applies to:

• Drug copayments;
• Limitations on service coverage (such as limits on the number of covered outpatient
visits);
• Use of care management tools (such as prescription drug rules and restrictions);
• Criteria for determining medical necessity and prior authorizations; and
• Prescription drug list structure, including copayments.

If you think that NH Healthy Families is not providing parity as explained above, you have the
right to file an appeal or file a grievance. For more information, refer to Chapter 10 (What to do
if you want to appeal a plan decision or “action”, or file a grievance).

If you think NH Healthy Families did not provide behavioral health services (mental health
and/or substance use disorder services) in the same way as medical services, you may also file a
grievance or complaint with the New Hampshire Department of Insurance Consumer Services
Hotline at 1-800-852-3416 (TDD Access Relay: 1-800-735-2964), Monday through Friday, 8:00
a.m. to 4:30 p.m. ET, or online at [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 94

Chapter 6. Rules on prior authorization of services

Prior authorization requirements for covered services are in italics in Section 4.2 (Benefits
Chart). For all services requiring prior authorization, your provider must request and receive
prior authorization from the NH Healthy Families in order for you to get coverage for the
service. If you do not get this authorization, NH Healthy Families may not cover the service.

For more information on how to get prior authorization for services, refer to Section 6.2 (Getting
plan authorization for certain services).

For information about how to get prior authorization for prescription drugs, refer to Section 7.1
(Drug coverage rules and restrictions: Getting plan authorization in advance).

Section 6.1 Medically necessary services

When making its coverage decision, NH Healthy Families will consider whether
the service is medically necessary

NH Healthy Families determines whether a service is "medically necessary" in a manner that is

no more restrictive than the New Hampshire Medicaid criteria. For information about criteria
used to support a medical necessity decision, call Member Services and request a copy of written
rules specific to your situation. (Phone numbers for Member Services are printed on the back
cover of this handbook.)

In some cases, NH Healthy Families will review medical necessity after covered services are
delivered.

Covered Services that you get must be Medically Necessary. This means getting the right care, at
the right place, at the right time. NH Healthy Families uses standard guidelines to check Medical
Necessity. NH Healthy Families has policies in place to ensure:

• Decisions are made based on the appropriateness of the care and service, and that health
insurance coverage is in place.
• The organization does not reward its Network Providers or their staff to deny coverage,
service, or care.
• Financial incentives for decision makers do not encourage decisions that result in denying
needed treatment.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 95

For members up to age 21 years “medically necessary” means the course of treatment:

• Is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the

worsening of conditions that:
o Endanger life,
o Cause pain,
o Result in illness or infirmity;
o Threaten to cause or aggravate a handicap;
o Cause physical deformity or malfunction; and
• No other equally effective course of treatment is available or suitable for the member.

For additional information about medically necessary services for members up to age 21, refer
to EPSDT services in Section 4.2 (Benefits Chart).

For members aged 21years and older, “medically necessary” means health care services that a
licensed health care provider, exercising prudent clinical judgment, would provide, in accordance
with generally accepted standards of medical practice to a member for the purpose of evaluating,
diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms.

Medically necessary health care services for members ages 21 years and older must be:

• Clinically appropriate in extent, site, and duration;

• Consistent with the established diagnosis or treatment of the recipient’s illness, injury,
disease, or its symptoms;
• Not primarily for the convenience of the member or the member’s family, caregiver, or
health care provider;
• No more costly than other items or services which would produce equivalent diagnostic,
therapeutic, or treatment results as related to the member’s illness, injury, disease, or its
symptoms; and
• Not experimental, investigative, cosmetic or duplicative in nature.

New Technology
NH Healthy Families evaluates new technology, including medical procedures, drugs and
devices, and the new application of existing technology, for coverage determination. The NH
Healthy Families medical director and/or medical management staff may periodically identify
relevant technological advances for review pertinent to the NH Healthy Families population. The
Clinical Policy Committee (CPC) reviews all requests for coverage and makes a determination
regarding any benefit changes that are indicated. When a request is received for coverage of new
technology that has not been reviewed by the CPC, the NH Healthy Families medical director will
review the request and make a one-time determination. This new technology request will then be
reviewed at the next regularly scheduled CPC meeting.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 96

Section 6.2 Getting plan authorization for certain services

For certain covered services, you or your provider will need to get approval from the plan before
we will agree to cover the service for you. This is called “prior authorization.” Sometimes the
requirement for getting approval in advance helps guide appropriate use of certain services. If
you do not get this approval, your service might not be covered by the plan.

When you need care, start with a call to your PCP. Some covered services may require prior
authorization. Prior authorization is a review by NH Healthy Families before you get certain
services. Prior authorization is needed for services or visits to an out of network provider and
some specialists. Home health services and some surgeries also need to be reviewed. Your doctor
can tell you if a service needs prior authorization. To find a list of services that need prior
authorization visit our website at [Link]. You can also call Member
Services at 1-866-769-3085 to see if something needs to be reviewed by NH Healthy Families.

Your doctor will give us information about why you need the service. NH Healthy Families will
look to see if the service is covered and that it is appropriate. NH Healthy Families clinical staff
will make the decision as soon as possible, based on your medical condition. Standard decisions
are made within 14 calendar days. If the service is urgent, the decision will be made within three
(3) business days. We will let you and your doctor know if the service is approved or denied. If
you or your doctor are not happy with the decision you can ask us for a second review. This is
called an appeal. See Chapter 10 for more information about appeals.

If there are any major changes to the prior authorization process, we will let you and your
doctors know right away.

Self – Referral

You may self-refer for certain covered services. This means, you do not need your PCP to
recommend you go see a specific provider. You can choose to see certain providers without checking
with your PCP first. It is always a good idea to inform your PCP of any other providers you see so
they can have a complete picture of your overall health. Always be sure to see a NH Healthy
Families network provider.

If you aren’t sure if you need a referral, contact your PCP or Member Services for assistance. Your
PCP can also tell you if a service requires a prior authorization.

Section 6.3 Getting authorization for out-of-network services

For information on how to get care from out-of-network providers, refer to Section 3.5 (Getting
care from out-of-network providers).

If you are an American Indian or Alaska Native (AI/AN) of a federally recognized tribe or
another individual determined eligible for Indian health care services, special coverage rules
apply. You may get out-of-network services at an Indian health facility without prior
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 97

authorization. Contact Member Services for more information (phone numbers are printed on the
back cover of this handbook).

Section 6.4 Out-of-network hospital admissions in an emergency

The general rules for coverage of out-of-network care are different for emergency care. For
information on how to get care from out-of-network hospitals in an emergency and for post
stabilization services, refer to Section 3.6 (Emergency, urgent, and after-hours care).

Section 6.5 Getting family planning services and supplies in- or

out-of-network
You may choose any doctor, clinic, community health center, hospital, pharmacy or family-planning
office in- or out-of-network. Family planning services do not need a referral.

The following services are covered:

• Family planning exam and medical treatment
• Family planning lab and diagnostic tests
• Family planning methods (birth control pills, patch, ring, IUD, injections or implants)
• Family planning supplies with prescription (condom, sponge, foam, film, diaphragm or cap)
• Counseling and testing for sexually transmitted infections (STIs), AIDS and other HIV-
related conditions
• Treatment for sexually transmitted infections (STIs)
• Voluntary sterilization, you must be 21 older, mentally competent and you must sign
a federal sterilization-consent form. At least 30 days, but not more than 180 days,
must pass between the date that you sign and the date of surgery.
• Voluntary hysterectomies are not covered for the sole purpose of sterilization.
Services must be deemed medically necessary and a signed Acknowledgement of
Sterilization due to Hysterectomy Form (910) is required to be reviewed and signed
by both the Member and rendering provider prior to the services being rendered.

Prior authorization is not required for services provided by a network provider.

Section 6.6 Getting a second medical opinion

Members may receive a second opinion from a qualified health care professional within the
network, or one may be arranged by NH Healthy Families outside the plan’s network at no cost
to you.

This means you can talk to a different doctor to get their point of view. Another opinion may
help you decide what treatment or service is best for you. Tell your primary care provider (PCP)
or call Member Services, if you want a second opinion.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 98

A second opinion:
• Is covered by NH Healthy Families at no cost to you.
• Is available from an in-network provider.
• Is available from an out-of-network provider with prior authorization.
• May lead to additional tests that require prior authorization.
• Will be reviewed by your PCP or specialist, who will help you decide on the best
treatment plan.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 99

Chapter 7. Getting covered prescription drugs

Section 7.1 Drug coverage rules and restrictions

The plan’s Preferred Drug List (PDL) includes information about the restrictions described
above. To find out if any of these restrictions apply to a drug you take or want to take, check the
Drug List. For the most up-to-date information, call Member Services (phone numbers are
printed on the back cover of this handbook) or check our website [Link]

If there is a restriction on your drug, it usually means that you or your provider will have
to take extra steps in order for the plan to cover the drug. If there is a restriction on the drug
you want to take, ask your doctor to request prior authorization from the plan. For more
information, contact Member Services (phone numbers are printed on the back cover of this
handbook.)

The plan will generally cover your drugs as long as you follow these basic rules:
• A NH Healthy Families network provider (a doctor or other qualified prescriber) writes
your prescription.
• The prescribing doctor (or other qualified prescriber) is enrolled with both New
Hampshire Medicaid and NH Healthy Families.
• You fill your prescription at a network pharmacy, unless otherwise allowed, as described
in section 7.4, “Fill your prescriptions at a network pharmacy.
• Your drug is on the plan’s Preferred Drug List.
• Your drug is to be used for a medically accepted reason, one that is either approved by
the Food and Drug Administration or supported by recognized publications.
• If a copayment is required, you pay the copayment for the prescription. However,
remember, that an inability to pay your copayment does not prevent you from getting
your prescription filled. (For more information on copayments, refer to Section 7.7,
Prescription drug copayments.

You or your provider may request an exception to drug coverage restrictions when you ask the
plan to allow you to get a drug that is not on the plan formulary. You may also request an
exception when the plan requires you to try another drug first or limits the quantity or dosage of
the drug you request, for example.

To fill your prescription, show your plan membership card at the network pharmacy you choose.
When you show your plan membership card, the network pharmacy will automatically bill the plan
for our share of your covered prescription drug cost. You will need to pay the pharmacy your share
of the cost when you pick up your prescription, if required. If you don’t have your plan membership
card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary
information.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 100

Drug coverage restrictions

For some prescription drugs, more detailed rules restrict how and when the plan covers them. A
team of doctors and pharmacists developed these rules to help our members use drugs in the
most safe and effective ways. These rules also help control overall drug costs, requiring a lower
cost drug if it works as well as a higher cost drug.

Drug list rule restrictions described in this section include:

• Restricting access to brand name drugs when a generic version of the drug is
available
• Requiring prior authorization from the plan
• Requiring you try a different but similar drug first (“step therapy”)
• Imposing quantity limits on prescription drugs

Restricting access to brand name drugs when a generic version is available

Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most
cases, when a generic version of a brand name drug is available and has been proven
effective for most people with your condition, network pharmacies will provide you the
generic version. We usually will not cover the brand name drug when a generic version is
available. However, if your provider has told us the medical reason that the generic drug will not
work for you OR has written “Brand Medically Necessary” on your prescription for a brand
name drug OR has told us the medical reason that neither the generic drug nor other covered
drugs that treat the same condition will work for you, then the plan will cover the brand name
drug.

Requiring prior authorization from the plan

Some drugs have limits or require NH Healthy Families to grant permission before your
prescription is covered. This is called a prior authorization. The pharmacist will inform the
doctor if a prior authorization is needed. Your doctor can ask NH Healthy Families to cover the
prescription if there is a medical reason. We will let you know if we do not grant the request for
prior authorization. We will also tell you how you can file an appeal of that decision.

Requiring you try a different but similar drug first (“step therapy”)

This requirement requires you try a less costly and equally effective drug before the plan covers
the more costly drug. For example, if Drug A and Drug B treat the same medical condition, the
plan may require you to try lower cost Drug A first. If Drug A does not work for you, the plan
will then cover the higher cost Drug B. This requirement to try a particular drug first is called
“step therapy.”

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 101

Imposing quantity limits on a prescription drug

For some drugs in the plan’s Preferred Drug List the plan limits the amount of the drug that you
can get each time you fill or refill your prescription. For example, if it is normally considered
safe to take only one pill per day for a certain drug, we may limit coverage for your prescription
to no more than 30 pills per refill and no more than one refill every 30 days. If you try to refill
your prescription too early, you may be asked by the pharmacist to refill your prescription later.

What to do if your drug has restrictions or is not on the plan formulary or drug list

If your drug is not on the Preferred Drug List or has restrictions, here are things you can do:

• Start by talking with your provider about your options.

• Sometimes you may be able to get a temporary supply of the drug. This will give
you and your provider time to change to another drug or to file a request to have
the drug covered.
o In these situations please contact Member Services (phone
numbers are printed on the back cover of this handbook) for an
override or have your pharmacist contact the pharmacy help desk
phone number (located on the back of you Member ID Card) to
get the override.
• You can change to another drug. You or your provider can request a list of
covered drugs that treat your condition from Member Services (phone numbers
are printed on the back cover of this handbook).
• You can request an exception and ask the plan to cover the drug or remove
restrictions from the drug. If there is a restriction for your drug, it usually means
that you or your provider will have to take extra steps in order for us to cover the
drug. If there is a restriction on the drug you want to take, you should contact
Member Services to learn what you or your provider would need to do to get
coverage for the drug.
• You can file an appeal or a grievance. Chapter 10 (What to do if you want to
appeal a plan decision or “action”, or file a grievance).
For more information, contact Member Services (phone numbers are printed on the back cover
of this handbook).

Section 7.2 Plan formulary or drug list

The plan has a Preferred Drug List (PDL) which is approved by the New Hampshire Department
of Health and Human Services (NH DHHS). The drugs on this list include both generic and
brand name drugs carefully selected by the plan with help from a team of doctors and
pharmacists. The NH Healthy Families List of Covered Drugs is called the Preferred Drug List
(PDL).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 102

A generic drug is a prescription drug that has the same active ingredients as the brand name drug.
Generally, it works as well as the brand name drug and usually costs less. There are generic drug
substitutes available for many brand name drugs.

What is not on the Preferred Drug List

The plan does not cover all prescription drugs. NH Healthy Families chooses which drugs to
cover and Medicaid law prohibits coverage of some drugs.

How to find out if a specific drug is on the Preferred Drug List

You may find out if a particular drug is on the Preferred Drug List by:

• Visiting the plan’s website ([Link]). The Preferred Drug

List on the website is always the most current.
• Calling and asking Member Services to find out if the drug is on the plan’s NH
Healthy Families Preferred Drug List. (Phone numbers for Member Services are
printed on the back cover of this handbook.)
• Calling and asking Member Services for a copy of the Preferred Drug List.
(Phone numbers for Member Services are printed on the back cover of this
handbook.)

Over-the-Counter Drugs

The plan also covers certain over-the-counter drugs when you have a prescription from your
provider. Some over-the-counter drugs are less expensive than prescription drugs and work just
as well. For more information on coverage of over-the-counter drugs, call Member Services
(phone numbers are printed on the back cover of this handbook).

The formulary or Preferred Drug List can change during the enrollment year

During the enrollment year, the plan may make changes to the Drug List. For example, the plan
might:

• Add or remove drugs from the Preferred Drug List. For example, NH Healthy
Families may add new generic or brand name drugs as they become available. NH
Healthy Families may remove a drug from the Preferred Drug List if it is recalled or it is
found to be ineffective.
• Add or remove a restriction on coverage for a drug. For more information about drug
coverage restrictions, refer to Section 7.3 (Drug coverage rules and restrictions) in this
chapter.
• Replace a brand name drug with a generic drug.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 103

In all cases, we first must get approval from the NH DHHS for changes to the plan’s Preferred
Drug List.

How you will find out if your drug coverage has changed

If the plan changes coverage of a drug you are taking, the plan will send you a written notice.

Examples of when your drugs may change include:

• When a drug is suddenly recalled by one or both the manufacturer or Food and Drug
Administration (FDA) because it has been found to be unsafe or for other reasons. If this
happens, the plan will immediately remove the drug from the Drug List. We will notify
you and your provider of this change right away. Your provider will work with you to
find another drug to treat your condition.

• If a brand name drug you are taking is replaced by a new generic drug, the pharmacy
will automatically substitute the generic for the brand name drug. If the brand name drug
is medically necessary, the prescriber must issue a new prescription stating “medical
necessary” for the brand name drug, and submit a prior authorization request to the plan
for review.

To get the most up-to-date information about which drugs are covered, visit
[Link] or call Member Services (phone numbers are printed on the back
cover of this handbook).

Section 7.3 Types of drugs we do not cover

This section tells you what types of prescription drugs are not covered.

To get drugs not covered by the plan, you must pay for them yourself. We will not pay for the
drugs listed in this section.

NH Healthy Families will not cover drugs in the following situations:

• You are eligible for Medicare and Medicare Part D, whether you are enrolled or not.
NH Healthy Families will not cover drugs covered by Medicare Parts A, B, or D if you
are eligible for Medicare coverage.
• The drug is purchased outside of the United States or its territories.
• A drug is for an off-label use and the use is not supported in a recognized publication.
(“Off-label use” is any use of the drug other than that indicated on the drug label
approved by the FDA. Recognized publications are the American Hospital Formulary
Service Drug Information, the DRUGDEX Information System, for cancer, the
National Comprehensive Cancer Network and Clinical Pharmacology, or their

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 104

successors.) (For members aged 21 years and older, an exception may apply for
medically necessary off-label use prescriptions.)

In addition, the plan does not cover the following categories of drugs:

• Drugs that are experimental or investigational and not approved by the FDA
• Drugs listed by the FDA as being DESI drugs or IRS drugs
• Drugs when used to enhance or promote fertility
• Drugs when used for the relief of cough or cold symptoms
• Drugs when used for cosmetic purposes or to promote hair growth
• Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra®,
Cialis®, Levitra, and Caverject
• Outpatient drugs for which the manufacturer seeks to require that associated tests or
monitoring services be purchased exclusively from the manufacturer as a condition of
sale
• Items which are free to the general public

Section 7.4 Filling your prescriptions at network pharmacies

In most cases, your prescriptions are covered only if they are filled at the plan’s network
pharmacies. A network pharmacy is a pharmacy that has a contract with the plan to provide
your covered prescription drugs.

To fill your prescription, show your plan membership card at a network pharmacy. When you
show your plan membership card, the network pharmacy will automatically bill the plan for our
share of your covered prescription drug cost. You will need to pay the pharmacy your share of
the cost (your copayment, if required) when you pick up your prescription. For more information
on copayments, refer to Section 7.7 (Prescription drug copayments).

If you do not have your plan membership card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessary information.

How to find a network pharmacy in your area

You may go to any of our network pharmacies. To find a network pharmacy, you can look in
your Provider Directory, visit our website ([Link]), or call Member
Services (phone numbers are printed on the back cover of this handbook).

If you switch from one network pharmacy to another, and you need a refill of a drug you have
been taking, you can ask to have your prescription transferred to your new network pharmacy.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 105

We will notify you if the pharmacy you have been using leaves the plan’s network. If your
pharmacy leaves the plan’s network, you will have to find a new pharmacy that is in the network.
To find another network pharmacy, you can get help from Member Services (phone numbers are
printed on the back cover of this handbook).

What if you need a specialized pharmacy

Sometimes prescriptions must be filled at a specialized network pharmacy. Specialized

pharmacies include pharmacies that supply drugs for home infusion therapy. Other specialty
pharmacies include:

• Pharmacies that supply drugs for home infusion therapy.

• Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a
long-term care facility (such as a nursing home) has its own pharmacy. If you are in a
LTC facility, we must ensure that you are able to routinely receive your benefits through
our network of LTC pharmacies, which is typically the pharmacy that the LTC facility
uses. If you have any difficulty accessing your benefits in a LTC facility, please contact
Member Services.

To locate a specialized network pharmacy, look in your Provider Directory on our website
[Link] or call Member Services (phone numbers are printed on the back
cover of this handbook).

When you may use an out-of-network pharmacy

In emergencies when no in-network pharmacy is available, you may contact Member Services
(phone numbers are printed on the back cover of this handbook) for an override to fill your
prescription at an out-of-network pharmacy. The pharmacy may have to contact the pharmacy
help desk phone number (located on the back of your membership card) in order to obtain this
override.

How you can get an emergency supply of your medication

In emergencies when you are unable to receive your medication due to the need for prior
authorization, your pharmacy may contact the Pharmacy Help Desk at 888-613-7051 for an
override to fill up to a 72-hour emergency supply of your medication in most circumstances. The
pharmacy help desk phone number is located on the back of your membership card.

How to get a temporary supply of your medication

In certain circumstances, you can get a temporary supply of your medication, such as when you
go on vacation or your medication is lost. Limitations may apply. In these situations please
contact Member Services (phone numbers are printed on the back cover of this handbook) for an
override or have your pharmacy contact the pharmacy help desk phone number (located on the
back of your membership card) to get the override.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 106

For lost medication overrides please contact Member Services (phone numbers are printed on the
back cover of this handbook) for an override or have the pharmacy contact the pharmacy help
desk phone number (located on the back of your membership card) in order to obtain this
override. NH Healthy Families may require proof of loss in certain circumstances such as stolen
medication in the form of a police report.

Using the plan’s mail-order services

For certain types of drugs, you may use the plan’s network mail-order services. Generally, the
drugs provided through mail order are drugs that you take on a regular basis for a chronic or
long-term medical condition.

To get information about filling your prescriptions by mail please contact Member Services
(phone numbers are printed on the back cover of this handbook).

Usually a mail-order pharmacy order will get to you in no more than two business days. If your
medication delivery will not arrive in time for your treatment, please call Member Services
(phone numbers are printed on the back cover of this handbook). Member Services will assist
you by helping to get your medication from a different pharmacy.

The pharmacy will contact you each time it refills your medication or gets a new prescription
from a health care provider to see if you want the medication filled and shipped immediately.
This will give you an opportunity to make sure that the pharmacy is delivering the correct drug
(including strength, amount, and form) and, if necessary, allow you to cancel or delay the order
before it is billed and shipped. It is important that you respond each time you are contacted by
the pharmacy to let them know what to do with the new prescription and to prevent any delays in
shipping.

To ensure the pharmacy can reach you to confirm your order before shipping, make sure to let
the pharmacy know the best ways to contact you by calling Member Services (phone numbers
are printed on the back cover of this handbook).

To opt out of automatic deliveries of new prescriptions received directly from your health care
provider’s office, please contact the plan by calling Member Services.

It is important that you tell the pharmacy the best ways to contact you.

Section 7.5 Drug coverage in facilities

If you are admitted to a hospital or another facility for a stay covered by the plan, we will
generally cover the cost of your prescription drugs during your stay. Once you leave the hospital
or another facility, the plan will cover your drugs as long as the drugs meet all of our rules for
coverage described in this Chapter.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 107

What if you are a resident in a long-term care (LTC) facility?

Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a
network pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term
care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is
part of our network.

Check your Provider Directory by viewing it online or calling member services to find out if
your long-term care facility’s pharmacy is part of our network. If it is not listed in our network,
or if you need more information, please contact Member Services (phone numbers are printed on
the back cover of this handbook).

Section 7.6 Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe and
appropriate care. These reviews are especially important for members who have more than one
provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis.
During these reviews, we look for potential problems such as:

• Possible medication errors;

• Drugs that may not be necessary because you are taking another drug to treat the same
medical condition;
• Drugs that may not be safe or appropriate because of your age or gender;
• Certain combinations of drugs that could harm you if taken at the same time;
• Prescriptions that have ingredients you are allergic to; and
• Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your provider to
correct the problem.

Section 7.7 Prescription drug copayments

A copayment may be required for each prescription

You will be charged a copayment at the pharmacy for your covered prescription drugs unless the
prescription category is exempted or you are in one of the member exempt categories, as
described below (see Members who are exempt from copayments).

A “copayment” or “copay” is the fixed amount you may pay each time you fill and refill a
prescription. Prescription drug copayment amounts are subject to change.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 108

In 2018, prescription drug copayments are:

• $1 copayment for each preferred prescription drug, approved by the New Hampshire
Department of Health and Human Services (NH DHHS). The drugs on this list include
both generic and brand name drugs carefully selected by the plan with help from a team
of doctors and pharmacists. The NH Healthy Families List of Covered Drugs is called
“Preferred Drug List (PDL).”
• $2 copayment for each non-preferred prescription drug (if the prescribing provider
determines that a preferred drug will be less effective and/or will have adverse effects for
the member, the non-preferred drug will be $1.00). NH Healthy Families Incorporates a
Preferred Drug List. A notation of ‘Non-Formulary’ corresponds to drugs identified on
the NH Healthy Families PDL indicating the trial and failure of preferred alternatives.
The number of preferred drugs that must be tried prior to approval of non-formulary
drugs varies by therapeutic drug class. To request approval of a non-formulary drug
please submit rational via prior authorization request form to Envolve Pharmacy
Solutions (fax 1-866-399-0929.)
• $1 copayment for a prescription drug that is not identified as either a preferred or non-
preferred prescription drug.
• Copayments are not required for family planning products or for Clozaril® (Clozapine)
prescriptions.

Members who are exempt from copayments

NH DHHS determines whether you are exempt from prescription copayments.

You do not have to pay a copayment if:

• You fall under the designated income threshold (100% or below the federal poverty
level);
• You are under age 18 years;
• You are in a nursing facility or in an intermediate care facility for individuals with
intellectual disabilities;
• You participate in one of the Home and Community Based Care (HCBC) waiver
programs;
• You are pregnant and receiving services related to your pregnancy or any other medical
condition that might complicate your pregnancy;
• You are receiving services for conditions related to your pregnancy and your prescription
is filled or refilled within 60 days after the month your pregnancy ended;
• You are in the Breast and Cervical Cancer Program;
• You are receiving hospice care; or
• You are a Native American or Alaskan Native.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 109

If you believe you may qualify for any of these exemptions and are charged a copayment,
contact NH DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447)
(TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET.

You may be eligible for copayment reimbursement

NH DHHS offers eligible members copayment reimbursement. The information in this section
applies to you only if:

• You are required to pay prescription drug copayments; and

• You want to seek reimbursement for copayments your household may have overpaid.

To learn whether you are required to pay prescription drug copayments in our plan, refer to
Section 7.7 (Prescription drug copayments: Members who are exempt from copayments).

What you need to know if you are responsible for copayments and want to seek reimbursement
from NH DHHS for any overpayments you may have made:

• You are only responsible for copayments up to a maximum household dollar amount per
calendar quarter based on household income as reported during your New Hampshire
Medicaid eligibility process.
• For the 12-month period beginning January 1, 2018, the maximum dollar amount for a
household size of one (1) person is the lesser of $150.75 or 5 percent (5%) of household
income per calendar quarter. The maximum dollar amount varies by household size.
Copayments you and your family members pay under and NH Healthy Families apply to
your household maximum dollar amount.
• Once you and other members of your household pay the maximum dollar amount in a
calendar quarter, you are not responsible for any more copayments for the remainder of
that quarter.
• You and other members of your household will be required to pay copayments at the start
of each new quarter until the maximum dollar amount is met for the quarter.
• If you want to collect reimbursement for any overpayments you and other members of
your household have made, you must provide proof of all your paid copayments for each
quarter and submit detailed information regarding each copayment transaction to NH
DHHS.

If you want more information, including what you need to submit for reimbursement purposes,
contact NH DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447)
(TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 110

Chapter 8. Asking us to pay

Section 8.1 Network providers may not charge you for

covered services

With the exception of prescription drug copayments, network providers may not bill you for
covered services. You should never get a bill from a network provider for covered services as
long as you follow the rules outlined in this handbook.

We do not allow providers to bill members or add additional or separate charges, called “balance
billing.” (For a definition of balance billing, refer to Section 13.2 (Definitions of important
words).) This protection (that you never pay more than your copayment amount, if applicable)
applies even if we pay the provider less than the provider charges for a service. It also applies
when there is a dispute about the plan’s payment to the provider for a covered service, and when
we do not pay certain provider charges.

Sometimes when you get health care or a prescription drug, you may need to pay the full cost
right away. Other times, you may find that you have paid more than you expected under the
coverage rules of the plan. In either case, all you need do is ask the plan to pay you back.

There may also be times when a provider bills you for the full cost of health care you have
received. If you think we should have paid for some or all of these services, you should send
the bill to us instead of paying it, or notify the provider to bill the plan.
For information on where to send your request for payment, refer to Section 8.2 (How and where
to send us your request for payment).

Here are examples of situations in which you may need to ask the plan to pay you back, or to pay
a bill you have received:

• You’ve received emergency or urgently needed health care services or

prescription drugs from a provider who is not in the plan’s network
Ask the provider to bill the plan. You are only responsible for paying your share of the
cost for any prescription filled at a retail pharmacy.
If you pay all or part of the cost at the time you receive the health care service or
prescription drug, ask the plan to pay you back for its share of the cost. Send us the bill,
along with any documentation of payments you have made, such as a receipt.
If you get a bill from a provider asking for payment that you think you do not owe, send
the bill to the plan, along with documentation of any payments you have already made,
such as a receipt. If the provider is due payment, we will pay the provider directly. If you
have already paid more than your share of the cost of the bill, we will pay you back for
the plan’s share of the cost. If you received and were billed for services not covered by
the plan, you may be responsible for those costs.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 111

For information on where to send your request for payment, refer to Section 8.2 (How
and where to send us your request for payment).

• When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly. But sometimes they make
mistakes and bill you in error.
When this occurs:
o Send us the bill. We will contact the provider directly and resolve the billing
problem.
o If you have already paid the bill, but you think that you paid too much, send us
the bill along with documentation of any payment you have made and ask us to
pay you back the difference between the amount you paid and the amount you
owed under the plan.
For information on where to send your request for payment, refer to Section 8.2 (How
and where to send us your request for payment).

• When you pay the full cost for a prescription because you do not have your
plan membership card with you
If you do not have your plan membership card with you, ask the pharmacy to call the plan
or to look up your plan enrollment information. If the pharmacy cannot get the needed
enrollment information, you may be asked to pay the full cost of the prescription
yourself. If you pay for the prescription, save your receipt, send a copy to us, and ask us
to pay you back for our share of the cost
For information on where to send your request for payment, refer to Section 8.2 (How
and where to send us your request for payment).

• When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not
covered for some reason. For example, the drug may not be on the plan’s List of Covered
Drugs (Formulary); or it could have a requirement or restriction that was not followed. If
you decide to get the drug immediately, you may need to pay the full cost for it. Save
your receipt, send a copy to us, and ask us to pay you back for our share of the cost.
In some situations, we may need to get more information from your doctor in order to
pay you back for our share of the cost. If you received and were billed for services not
covered by the plan, you may be responsible for those costs.

For information on where to send your request for payment, refer to Section 8.2
(How and where to send us your request for payment).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 112

All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, you can appeal our decision or file a grievance. For information on how to
make an appeal or file a grievance, refer to Chapter 10 (What to do if you want to appeal a plan
decision or “action”, or file a grievance).

Section 8.2 How and where to send us your request for payment

Send us your request for payment, along with a copy of your bill and documentation of any
payment you have made. It is a good idea to keep a copy of your bills and receipts for your
records.

How and where to send us your request for payment

To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
• You do not have to use our claim form, but it will help us process the information faster.
• Either download a copy of the claim form from our website
([Link]) or call Member Services and ask for the claim form.
(Phone numbers for Member Services are printed on the back cover of this handbook.)

Send us your request for payment, along with your bill and documentation of any payment you
have made. It is a good idea to make a copy of your bill and receipts for your records.

Send payment requests to:

NH Healthy Families
Attn: Member Services
2 Executive Park Drive
Bedford, NH 03110

If you do not know what you should have paid, or you receive a bill that you do not understand,
contact Member Services (phone numbers are printed on the back cover of this handbook.). We
can help. You can also call the plan if you want to give us more information about a request for
payment you have already sent to the plan.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 113

Section 8.3 After the plan receives your request for payment

When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will review your request and make a coverage decision.

• If we decide that the health care service or prescription drug is covered and you followed
all the rules for getting the service or drug, we will pay for our share of the cost.
o If you have already paid for the service or drug, we will mail a reimbursement of
our share of the cost to you. If you do not agree with the amount we are paying
you, you may file an appeal.
o If you have not paid for the service or drug yet, we will mail the payment directly
to the provider.
• If we decide that the health care service or prescription drug is not covered, or you did not
follow all the rules, we will not pay for our share of the cost. Instead, we will send you a
letter that explains the reasons why we are not sending the payment you have requested
and your rights to appeal that decision.

If you think we have made a mistake in turning down your request for payment or you do not
agree with the amount we are paying, you can file an appeal. If you file an appeal, it means you
are asking the plan to change the decision we made when we turned down your request for
payment. For information on how to file an appeal, go to Chapter 10 (What to do if you want to
appeal a plan decision or “action”, or file a grievance).

Section 8.4 Payment rules to remember

NH Healthy Families covers all health care services that are medically necessary, are listed in the
plan’s Benefits Chart in Chapter 4 of this handbook, and are obtained consistent with plan rules.
You are responsible for paying the full cost of services that are not covered by the plan. Such
payments may be required because the service is not a covered service, or it was obtained out-of-
network and not authorized by the plan in advance.

For covered services that have a benefit limit, you pay the full cost of any services you get after
you have used up your benefit for that type of covered service. You can call Member Services
when you want to know how much of your benefit limit you have already used. (Phone numbers
for Member Services are printed on the back cover of this handbook.)

If you have any questions about whether we will pay for any health care service or care that you
are considering, you have the right to ask us whether we will cover it before you get it. You also
have the right to ask for this in writing. If we say we will not cover your services or
prescriptions, you have the right to file a grievance or appeal our decision not to cover your care.
For information on how to file an appeal, go to Chapter 10 (What to do if you want to appeal a
plan decision or “action”, or file a grievance).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 114

Chapter 9. Your rights and responsibilities

Section 9.1 Your rights

As a member of our plan, you have certain rights concerning your healthcare.

• You have the right to receive information in an easily understandable and readily
accessible format that meets your needs. For more information, refer to Section 2.13
(Other important information: Alternative formats and interpretation services).
• You have the right to be treated with respect and with due consideration for your dignity
and privacy.
• You have the right to receive information on available treatment options and alternatives,
presented in a manner appropriate to your condition and ability to understand.
• You have the right to participate in decisions regarding your health care, including the
right to refuse treatment.
• You have the right to receive information about the organization, its services, its
practitioners and providers and member rights and responsibilities.
• You have the right to make complaints or appeals about the organization or the care
provided, and to ask us to reconsider decisions that have been made.
• You have the right to make recommendations regarding the organization’s member rights
and responsibilities policy.
• You have the right to be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience or retaliation.
• You have the right to see, as well as request and receive a copy of your medical records,
and the right to request that your medical records be amended or corrected.
• You have the right to covered services and drugs that are available and accessible in a
timely manner.
• You have a right to care coordination.
• You have the right to privacy and protection of your personal health information.
• You have the right to receive information about our plan, our network providers, and your
covered services.
• You have the right to make decisions about your health care.
• You cannot be retaliated against in any way by the plan or by the New Hampshire
Department of Health and Human Services (NH DHHS) for exercising your rights.
• You have the right to a second opinion.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 115

• You have the right to know what to do if you are being treated unfairly or your rights are
not being respected. For more information, refer to Section 10.7 (How to file a grievance
and what to expect after you file).
• You have the right to be informed of any changes in state law that may affect your
coverage. The plan will provide you with any updated information at least thirty (30)
calendar days before the effective date of the change whenever practical.
• You have the right to exercise advance care planning for your health care decisions if you
so choose. For more information, refer to Section 9.3 (Advance care planning for your
health care decisions).
• You have the right to make a complaint if a provider does not honor your wishes
expressed in your advance directive. For more information, refer to Section 9.3 (Advance
care planning for your health care decisions).
• You have the right to leave our plan in certain situations. For more information, refer to
Section 11 (Ending your plan membership).
• You have a right to a candid discussion about treatment options, regardless of cost or
benefit coverage.
• In the case of a counseling or referral service that we do not cover because of moral or
religious objections, we must inform you that the service is not covered and how you can
obtain information on how to access this service.
• You are free to exercise your rights, and the plan shall assure that the exercise of those
rights shall not adversely affect the way plan and its providers or DHHS treat you.
• Information provided by us will reflect changes in State law as soon as possible, but no
later than ninety (90) calendar days after the effective date of the change;

Section 9.2 Your responsibilities

Below are things you need to do as a member of the plan. If you have any questions, please call
Member Services (phone numbers are printed on the back cover of this handbook).

• You have the responsibility to give NH Healthy Families practitioners and providers
complete and accurate information.
• You have the responsibility to follow plans and instructions that for treatment that
were agreed upon.
• You have the responsibility to understand your health problems and to participate in
developing mutually agreed upon treatment goals with your provider to the highest
degree possible.

• Get familiar with your covered services and the rules you must follow to get these
covered services. Use this handbook to learn what is covered, and the rules you need to
follow to get your covered services.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 116

o Chapters 3 and 4 give the details about your health care services, including what
is covered by the plan, what is not covered, and rules to follow.
o Chapter 7 provides details about prescription drug coverage, including what you
may be required to pay.
o To be covered by NH Healthy Families, you must receive all of your health care
from the plan’s network providers except:
 Emergency care;
 Urgently needed care when you are traveling outside of the plan’s service
area;
 Family planning services; and
 When we give you authorization in advance to get care from an out-of-
network provider.
• If you have any other health insurance coverage or prescription drug coverage in
addition to our plan, you are required to tell NH Healthy Families as soon as
possible. Please call Member Services to let us know (phone numbers are printed on the
back cover of this handbook).
We are required to follow rules set by Medicaid to make sure that you are using all of
your coverage. This is called “coordination of benefits” because it involves coordinating
the health and prescription drug benefits you get from our plan with any other health and
prescription drug benefits available to you. We will help you coordinate your benefits.
For more information about coordination of benefits, refer to Section 1.5 (How other
insurance works with our plan).
• Tell your doctor and other health care providers that you are enrolled in our plan.
Show your plan membership card and your New Hampshire Medicaid card whenever you
get your covered services, including medical or other health care services and
prescription drugs.
• Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help your doctors and other health care providers give you the best care, learn
as much as you are able to about your health conditions. Give your health care
providers the information they need about you and your health. Follow the
treatment plans and instructions that you and your doctors agree upon.
o Make sure your doctors and other health care providers know all of the drugs you
are taking, including over-the-counter drugs, vitamins, and supplements.
o Talk to your PCP about seeking services from a specialist before you go to one,
except in an emergency.
o Keep appointments, be on time, and call in advance if you are going to be late or
have to cancel your appointment.
o Authorize your PCP to get necessary copies of all of your health records from
other health care providers.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 117

o If you have any questions, be sure to ask. Your doctors and other health care
providers will explain things in a way you can understand. If you ask a question
and you do not understand the answer you are given, ask again.
• Request interpretation services if you need them. Our plan has staff and free language
interpreter services available to answer questions from non-English speaking members. If
you are eligible for New Hampshire Medicaid because of a disability, we are required to
give you information about the plan’s benefits that is accessible and appropriate for you
at no cost. For more information, refer to Section 2.13 (Other important information:
Alternative formats and interpretation services).
• Respect other members, plan staff and providers. For information about when
members may be involuntarily disenrolled for threatening or abusive behavior, refer to
Section 11.2 (When you may be involuntarily disenrolled from the plan).
• Pay what you owe. As a plan member, you are responsible for these payments, as
applicable:
o For prescription drugs covered by the plan, you must pay a copayment, if
required. However, any inability to pay your copayment does not prevent you
from getting your prescription filled. Refer to Chapter 7 (Getting covered
prescription drugs) to learn what you must pay for your prescription drugs.
o If you get any health care services or prescription drugs that are not covered by
our plan or by other insurance you have, you are responsible for the full cost.
o If you disagree with our decision to deny coverage for a health care service or
prescription drug, you can request an appeal. For information about how to
request an appeal, refer to Chapter 10 (What to do if you want to appeal a plan
decision or “action”, or file a grievance).
• Tell the plan if you move. If you are going to move or have moved, it is important to tell
us as soon as possible. Call Member Services (phone numbers are printed on the back
cover of this handbook).
• Do not allow anyone else to use your NH Healthy Families or New Hampshire
Medicaid membership cards. Refer to Section 2.12 (How to report suspected cases of
fraud, waste, and abuse). Notify us when you believe someone has purposely misused
your health care benefits.
• Call Member Services for help if you have questions or concerns. We also welcome
any suggestions you may have for improving our plan. (Phone numbers for Member
Services are printed on the back cover of this handbook).

Section 9.3 Advance care planning for your health care decisions

You have the right to say what you want to happen if you are unable to make
health care decisions for yourself

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 118

Sometimes people are unable to make their own health care decisions. Before that happens to
you, you can:

• Fill out a written form to give someone the right to make health care decisions for you;
and
• Give your doctors written instructions about how you want them to handle your health
care if you become unable to make decisions for yourself.

The legal documents you can use to give your directions are called “advance directives”. The
documents are a way for you to communicate your wishes to family, friends and health care
providers. It allows you to express your healthcare wishes in writing in case you cannot do so if
you are seriously sick or injured.

There are two types of advance directives in New Hampshire:

• Living Will – A document that tells your healthcare provider whether to give life-
sustaining treatment if you are near death or are permanently unconscious without hope
of recovery.

• Durable Power of Attorney for Healthcare – A document in which you name someone to
make health care decisions, including decisions about life support, if you can no longer
speak for yourself. This person is your healthcare “agent” and may also carry out the
wishes you described in your “Living Will.”

If you want to create an advance directive:

• Get the form from your doctor, your lawyer, a legal services agency, or a social worker.

• Fill out and sign the form. Remember, this is a legal document. You may want to have a
lawyer help you fill out the form.
• Give copies to people who need to know about it, including your doctor and the person
you name as your agent. You may also want to give copies to close friends or family
members.
• Be sure to keep a copy at home.
• If you are going to be hospitalized, take a copy of it to the hospital. The hospital will ask
you whether you have signed an advance directive form and whether you have it with
you. If you have not signed an advance directive form, the hospital will have forms
available and may ask if you want to sign one.

If you have signed an advance directive, and you believe that a doctor or hospital did not follow
the instructions in it, you may file a complaint with the New Hampshire Department of Health
and Human Services Ombudsman who can refer you to the appropriate agency or party. For
contact information, refer to Section 2.10 (How to contact the NH DHHS Ombudsman).
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 119

Remember, it is your choice to fill out an advance directive (including whether you want to sign
one if you are in the hospital). According to law, no one can deny you care or discriminate
against you based on whether or not you have signed an Advance Directive.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 120

Chapter 10. What to do if you want to appeal a plan decision

or “action”, or file a grievance

As a member of NH Healthy Families, you have the right to file an appeal or grievance if you are
dissatisfied with the plan in any way. Each appeal and grievance process has a set of rules,
procedures, and deadlines that you and the plan must follow. This chapter explains the two types
of processes for handling problems and concerns.

These are:

• Appeals process – For some types of problems, you need to use the NH Healthy Families
appeals process. In most cases, you must appeal to the plan and exhaust its appeal process
(first level appeal) before you request a State Fair Hearing with the NH DHHS
Administrative Appeals Unit (AAU) (second level appeal).
• Grievance process – For other types of problems, you need to use the NH Healthy
Families grievance process.

For help with your appeal or grievance, contact Member Services (phone numbers are printed on
the back cover of this handbook). You may also contact the NH DHHS Customer Service Center
at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-735-2964), Monday through
Friday, 8:00 a.m. – 4:00 p.m. ET.

Section 10.1 About the appeals process

Whenever NH Healthy Families makes a coverage decision or takes an action that you disagree
with, you may file an appeal. If NH Healthy Families denies, reduces, suspends, or ends your
health care services, the plan must send you a written notice within at least 10 calendar days
before taking the action. The written notice must explain the reason for the “action,” specify
the legal basis that supports it, and include information about the appeal process. If you decide to
appeal the plan’s decision, it is very important to review the plan’s written notice carefully and
follow the deadlines for the appeal process.

Plan “actions” that may be appealed include:

• A decision to deny or limit a requested health care service or request for prior
authorization in whole or in part;
• A decision to reduce, suspend, or end health care service that you are getting;
• A decision to deny a member request to dispute a financial liability, including cost-
sharing, copayments, and other enrollee financial liabilities. This includes denial for
payment of a service, in whole or in part; and
• When a member is unable to access health care services in a timely manner.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 121

You have the right to file an appeal even if no notice was sent by the plan. If you receive a verbal
denial, you should request a written denial notice from the plan and appeal after receiving the
verbal and/or written denial notice if you are dissatisfied with the plan’s decision.

There are two levels of appeal.

These are:

• First level standard or expedited appeals through the plan. At this level of appeal, you
ask NH Healthy Families to reconsider its decision to a particular “action”. First level
appeals include both standard and expedited appeals. The exception to first level appeal
requirements is when the plan misses the timeframe to provide you with timely written
notice of its decision. When this happens, you have the right to file a State Fair Hearing
appeal immediately.

For more information about standard appeals, refer to Section 10.2 (How to file a standard
appeal and what to expect after you file (standard first level appeal)).

For more information about expedited appeals, refer to Section 10.3 (How to file an
expedited appeal and what to expect after you file (expedited first level appeal)).

• Second level standard or expedited State Fair Hearing appeals. Before you file a State
Fair Hearing appeal with NH DHHS AAU, you must exhaust the first level of appeal
through NH Healthy Families.

For more information about standard State Fair Hearing appeals, refer to Section 10.4
(How to file a standard State Fair Hearing appeal and what to expect after you file
(standard second level appeal)).

For more information about expedited State Fair Hearing appeals, refer to Section 10.5
(How to file an expedited State Fair Hearing appeal and what to expect after you file
(expedited second level appeal)).

For help with your appeal, contact Member Services (phone numbers are printed on the back
cover of this handbook).

Section 10.2 How to file a standard appeal and what to expect after
you file (standard first level appeal)
To file a standard appeal (first level appeal) with the plan:

• You must file your standard appeal with NH Healthy Families over the phone or in
writing within 60 calendar days of the date of the plan’s written notice to you. Your
oral request for a standard appeal must be followed by a written and signed appeal
request from you.
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 122

• In your signed, written appeal request:

o Include your name, address, phone number, and email address (if you have one);
o Describe the date of the action or notice from the plan you want to appeal, and
attach a copy of the notice;
o Explain why you want to appeal the decision; and
o If the plan’s decision was to deny, reduce, limit, suspend or end your previously
authorized benefits, indicate whether you want to have previously authorized
benefits continued. For more information, refer to Section 10.6 (How to request
continuation of benefits during appeal and what to expect afterward).

• Send your written plan appeal request to:

NH Healthy Families
Attn: Grievances and Appeals
2 Executive Park Drive
Bedford, NH 03110
Fax Number: 1-866-270-9943

• You may designate someone to file the appeal for you, including your provider.
However, you must give written permission to name your provider or another person to
file an appeal for you. For more information about how to appoint another person to
represent you, refer to Section 2.13 (Other important information: You may designate an
authorized representative or personal representative).
• If you appeal the plan’s decision to deny, reduce, limit, suspend or end services, you
may have a right to request continuation of benefits from NH Healthy Families
during your appeal. Your provider cannot request continuation of benefits for you.
For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

Here is what you can expect after you file your standard appeal with the plan:

• After you file your standard appeal, you have the right to request and receive a copy
of your case file that the plan used to make its decision. A copy of your case file is free
of charge and may be requested in advance of the plan’s decision.
• NH Healthy Families must provide you with reasonable opportunity to present evidence in
person as well as in writing as part of the appeal.
• For a standard appeal, NH Healthy Families will issue its written decision within 30
calendar days after receipt of your appeal request. The plan may take up to an
additional 14 calendar days if you request the extension, or if the plan needs additional
information and feels the extension is in your best interest. If the plan decides to take extra
days to make the decision, the plan will tell you in writing. If you disagree with the plan’s

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 123

extension, you may file a grievance with the plan. For more information, refer to Section
10.7 (How to file a grievance and what to expect after you file).
• If NH Healthy Families reverses its decision to deny, reduce, limit, suspend, or end
services that were not provided while the appeal was pending, NH Healthy Families
will authorize the services promptly. The services will be authorized as expeditiously
as your health condition requires, but no later than 72 hours from the date the plan
reversed its decision.
• If you received continued benefits while the appeal was pending:

o If the decision is in your favor, the plan will pay for those services.
o If you lose your appeal and received continued benefits you may be responsible for
the cost of any continued benefits provided by the plan during the appeal period.

For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

• If you are dissatisfied with the results of your first level appeal from NH Healthy
Families, you may file a second level of appeal by requesting a standard or
expedited State Fair Hearing. For more information, refer to Section 10.4 (How to file a
standard State Fair Hearing appeal and what to expect after you file (standard second
level of appeal) and Section 10.5 (How to file an expedited State Fair Hearing and what
to expect after you file (expedited second level of appeal)).

For help with your appeal, contact Member Services (phone numbers are printed on the back
cover of this handbook).

Section 10.3 How to file an expedited appeal and what to expect

after you file (expedited first level appeal)

If taking the time for standard resolution of your appeal would seriously jeopardize your life or
health, or ability to attain, maintain, or regain maximum function, you may request expedited
resolution of your appeal from NH Healthy Families. This is sometimes called “asking for a fast
decision”.

To file an expedited appeal (first level appeal) with the plan:

• You must file your expedited appeal with NH Healthy Families over the phone or in
writing within 60 calendar days of the date of the health plan’s written notice to you.
When you contact the plan, remember to ask for an expedited appeal.
• In your signed, written expedited appeal request:

o Include your name, address, phone number, and email address (if you have one);

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 124

o Describe the date of the action or notice from the plan you want to appeal, and
attach a copy of the notice;
o Explain the reason for your expedited request and why you want to appeal the
decision; and
o If the plan’s decision was to deny, reduce, limit, suspend or end your previously
authorized benefits, indicate whether you want to have previously authorized
benefits continued. For more information, refer to Section 10.6 (How to request
continuation of benefits during appeal and what to expect afterward).

• Send your written appeal request to:

NH Healthy Families
Attn: Grievances and Appeals
2 Executive Park Drive
Bedford, NH 03110
Fax Number: 1-866-270-9943

• You may designate someone to file the appeal for you, including your provider.
However, you must give written permission to name your provider or another person to
file an appeal for you. The plan does not need written permission if your provider is
requesting the expedited first level appeal on your behalf. For more information about
how to appoint another person to represent you, refer to Section 2.13 (Other important
information: You may designate an authorized representative or personal representative).
• If you appeal the plan’s decision to deny, reduce, limit, suspend or end services, you
may have a right to request continuation of benefits from NH Healthy Families
during your appeal. Your provider cannot request continuation of benefits for you.
For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

Here is what you can expect after you file your expedited appeal with the plan:

• After you file your expedited appeal, you have the right to request and receive a copy
of your case file that the plan used to make its decision. A copy of your case file is free
of charge and may be requested in advance of the plan’s decision.
• If NH Healthy Families accepts your request for an expedited appeal, it must provide you
with reasonable opportunity to present evidence in person as well as in writing as part of
the appeal. You must keep in mind that this may be difficult to do with an expedited “fast”
appeal decision.
• For an expedited appeal, NH Healthy Families must resolve your request as
expeditiously as your health condition requires, but no later than 72 hours after the
date the plan receives your request. The plan may take up to 14 calendar days if you
request an extension, or if the plan needs additional information and feels the extension is
in your best interest. If the plan decides to take extra days to make a decision, the plan will
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 125

attempt to inform you with prompt verbal notice of the delay, and tell you in writing
within 2 calendar days. If you disagree with the plan’s extension, you may file a grievance
with the plan. For more information, refer to Section 10.7 (How to file a grievance and
what to expect after you file).
• If NH Healthy Families accepts your request for an expedited appeal, the plan will issue
its written decision as expeditiously as your health condition requires, but no later than 72
hours after the date the plan receives your request.
• If NH Healthy Families denies your request for an expedited appeal, the plan must make
reasonable efforts to give you prompt verbal notice of the denial, and then must provide
written notice of the denial within 2 calendar days.
• You have the right to file a grievance with NH Healthy Families if the plan denies
your request for an expedited appeal. If the plan denies your request for an expedited
appeal, NH Healthy Families will treat your appeal as part of the standard appeal process.
• If NH Healthy Families reverses its decision to deny, reduce, limit, suspend, or end
services that were not provided while the appeal was pending, NH Healthy Families
will authorize the services promptly. The services will be authorized as expeditiously
as your health condition requires, but no later than 72 hours from the date the plan
reversed its decision.
• If you received continued benefits while the appeal was pending:

o If the decision is in your favor, the plan will pay for those services.
o If you lose your appeal and received continued benefits you may be responsible for
the cost of any continued benefits provided by the plan during the appeal period.

For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

• If you are dissatisfied with the results of your first level appeal from NH Healthy
Families, you may file a second level of appeal by requesting a standard or
expedited State Fair Hearing. For more information, refer to Section 10.4 (How to file a
standard State Fair Hearing appeal and what to expect after you file (standard second
level appeal) and Section 10.5 (How to file an expedited State Fair Hearing and what to
expect after you file (expedited second level appeal)).

For help with your appeal, contact Member Services (phone numbers are printed on the back
cover of this handbook).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 126

Section 10.4 How to file a standard State Fair Hearing appeal and
what to expect after you file (standard second level
appeal)

If you are dissatisfied with the results of your first level appeal from NH Healthy Families,
you may file a second level of appeal by requesting a State Fair Hearing with the NH
DHHS Administrative Appeals Unit (AAU).

To file a standard State Fair Hearing appeal (second level appeal):

• You must request a standard State Fair Hearing in writing within 120 calendar days
of the date on the plan’s written decision. In most situations, you cannot request a State
Fair Hearing without first going through the plan’s standard or expedited (first level
appeal) processes described above. For exceptions to when you do not have to exhaust the
plan’s appeal process before requesting a State Fair Hearing appeal, refer to Section 10.1
(About the appeals process).
• In your signed, written standard State Fair Hearing request:

o Include your name, address, phone number, and email address (if you have one);
o Describe the date of the action or notice from the plan you want to appeal, and
attach a copy of the notice;
o Explain why you want to appeal the decision;
o If the plan’s decision was to deny, reduce, limit, suspend or end your previously
authorized benefits, indicate whether you want to have previously authorized
benefits continued. You must contact the plan to request continuation of benefits.
For more information, refer to Section 10.6 (How to request continuation of
benefits during appeal and what to expect afterward); and
o Describe any special requirements you will need for the hearing (e.g., handicap
accessibility, interpretation services).

• Send your written State Fair Hearing request to:

Administrative Appeals Unit

NH Department of Health and Human Services
105 Pleasant Street, Room 121C
Concord, NH 03301
Fax: 603-271-8422
• If you appeal the plan’s decision to deny, reduce, limit, suspend or end services, you
may have a right to request continuation of benefits from NH Healthy Families
during your appeal. Your provider cannot request continuation of benefits for you.
For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 127

Here is what you can expect after you file your standard State Fair Hearing appeal:

• After you file your standard State Fair Hearing appeal, you have the right to request
and receive a copy of your case file that the plan used to make its decision. A copy of
your case file is free of charge and may be requested in advance of the State Fair Hearing
decision.
• For a standard State Fair Hearing appeal, the AAU must resolve your request as
expeditiously as your health condition requires, but no later than 90 days after the
date you filed your first level appeal with the plan (excluding the number of days it
took you to request the State Fair Hearing).
• The AAU will let you know where the hearing will take place. Hearings are usually held
at the AAU in Concord, or at your local NH DHHS District Office.
• A hearing officer from the AAU will conduct the hearing.
• You may bring witnesses, present testimony and evidence in person as well as in writing,
and question other witnesses at your State Fair Hearing.
• If the AAU reverses the plan’s decision to deny, reduce, limit, suspend, or end
previously authorized benefits that were not provided while the first level appeal
and/or State Fair Hearing were pending, the plan will authorize the services as
expeditiously as your health condition requires, but no later than 72 hours from the
date the plan receives notice that the AAU reversed the plan’s decision.
• If you received continued benefits while the appeal was pending:

o If the decision is in your favor, the plan will pay for those services.
o If you lose your appeal and received continued benefits you may be responsible for
the cost of any continued benefits provided by the plan during the appeal period.

For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

For more information, contact the AAU at 1-800-852-3345, extension 4292, Monday through
Friday, 8:00 a.m. – 4:00 p.m. ET. You may also contact the NH DHHS Customer Service Center
at 1-ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-735-2964), Monday through
Friday, 8:00 a.m. – 4:00 p.m. ET.

Section 10.5 How to file an expedited State Fair Hearing appeal

and what to expect after you file (expedited second
level appeal)

If you are dissatisfied with the results of your first level appeal from NH Healthy Families
AND any delay of services could seriously jeopardize your life, physical or mental health,

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 128

or ability to attain, maintain, or regain maximum function, you may file an expedited State
Fair Hearing with the NH DHHS Administrative Appeals Unit (AAU).

To file an expedited State Fair Hearing appeal (second level appeal):

• It is important for you to request an expedited State Fair Hearing appeal in writing
immediately upon receipt of the plan’s written decision. If your appeal is to continue
benefits for previously authorized services, you must also request continuation of
benefits at the same time you file your expedited State Fair Hearing appeal. For more
information, refer to Section 10.6 (How to request continuation of benefits during appeal
and what to expect afterward).

In most situations, you cannot request a State Fair Hearing without first going through the
plan’s standard or expedited (first level appeal) processes described above. For exceptions
to when you do not have to exhaust the plan’s appeal process before requesting a State
Fair Hearing appeal, refer to Section 10.1 (About the appeals process).
• In your signed, written expedited State Fair Hearing request:

o Include your name, address, phone number, and email address (if you have one);
o Describe the date of the action or notice from the plan you want to appeal, and
attach a copy of the notice;
o Specify that you want an expedited State Fair Hearing;
o Explain how any delay of services could seriously jeopardize your life,
physical or mental health, or ability to attain, maintain, or regain maximum
function;
o If the plan’s decision was to deny, reduce, limit, suspend or end your previously
authorized benefits, indicate whether you want to have previously authorized
benefits continued. You must contact the plan to request continuation of benefits.
For more information, refer to Section 10.6 (How to request continuation of
benefits during appeal and what to expect afterward); and
o Describe any special requirements you will need for the hearing (e.g., handicap
accessibility, interpretation services).

• Send your written State Fair Hearing request to:

Administrative Appeals Unit

NH Department of Health and Human Services
105 Pleasant Street, Room 121C
Concord, NH 03301
Fax: 603-271-8422
• You may designate someone to file the appeal for you, including your provider.
However, you must give written permission to name your provider or another person to

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 129

file an appeal for you. For more information about how to appoint another person to
represent you, refer to Section 2.13 (Other important information: You may designate an
authorized representative or personal representative).
• If you appeal the plan’s decision to deny, reduce, limit, suspend or end services, you
may have a right to request continuation of benefits from NH Healthy Families
during your appeal. Your provider cannot request continuation of benefits for you.
For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

Here is what you can expect after you file your expedited State Fair Hearing appeal:

• After you file your expedited State Fair Hearing appeal, you have the right to request
and receive a copy of your case file that the plan used to make its decision. A copy of
your case file is free of charge and may be requested in advance of the State Fair Hearing
decision.
• If the AAU accepts your request for an expedited State Fair Hearing appeal, the AAU will
issue its written decision as expeditiously as your health condition requires, but no later
than 3 business days after the AAU receives the plan’s case file and any additional
information for your appeal.
• If the AAU denies your request for an expedited State Fair Hearing appeal, the AAU will
make reasonable efforts to give prompt verbal notice to you, and provide written notice of
the denial. If your expedited request is denied, your appeal will be treated as a standard
State Fair Hearing appeal described in Section 10.4 (How to file a standard State Fair
Hearing appeal and what to expect after you file (second level appeal)).
• The AAU will let you know where the hearing will take place. Hearings are usually held
at the AAU in Concord, or at your local NH DHHS District Office.
• A hearing officer from the AAU will conduct the hearing.
• You may bring witnesses, present testimony and evidence in person as well as in writing,
and question other witnesses at your State Fair Hearing.
• If the AAU reverses the plan’s decision to deny, reduce, limit, suspend, or end
previously authorized benefits that were not provided while the first level appeal
and/or State Fair Hearing were pending, the plan will authorize the services as
expeditiously as your health condition requires, but no later than 72 hours from the
date the plan receives notice that the AAU reversed the plan’s decision.
• If you received continued benefits while the appeal was pending:

o If the decision is in your favor, the plan will pay for those services.
o If you lose your appeal and received continued benefits you may be responsible for
the cost of any continued benefits provided by the plan during the appeal period.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 130

For more information, refer to Section 10.6 (How to request continuation of benefits
during appeal and what to expect afterward).

For more information, contact the AAU at 1-800-852-3345, extension 4292, Monday through
Friday, 8:00 a.m. – 4:00 p.m. ET. You may also contact the NH DHHS Customer Service Center
at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-735-2964), Monday
through Friday, 8:00 a.m. – 4:00 p.m. ET.

Section 10.6 How to request continuation of benefits during appeal

and what to expect afterward

As described in previous sections of this chapter, if you appeal the plan’s decision to deny,
reduce, limit, suspend or end previously authorized benefits, you may have a right to request
continued benefits from NH Healthy Families pending the outcome of one or both your first
and/or second level appeal. While you may designate someone to file an appeal for you,
your provider cannot request continuation of benefits for you.

• The plan must continue benefits at your request when the following occur:

For standard and expedited plan appeals For standard and expedited State Fair
(first level appeal) Hearing appeals (second level appeal)
o Within 10 calendar days of the date o Within 10 calendar days of the date
you receive the notice of action from you receive the first level appeal notice
the plan or the intended effective date of action from the plan or the intended
of the plan’s action, you file your first effective date of the plan’s action, you
level appeal orally or in writing (oral file your second level appeal in writing
appeals must be followed up in writing) AND you request continuation of
AND you request continuation of benefits pending the outcome of one or
benefits pending the outcome of your both your first and/or second level
first level appeal, orally or in writing; appeal, orally or in writing
and
o The appeal involves the termination, If you did not request continuation of benefits
suspension, or reduction of a previously during your first level appeal with the plan,
authorized course of treatment; and the following conditions also apply:

o The service was ordered by an authorized o The appeal involves the termination,
provider; and suspension, or reduction of a previously
o The original authorization period for the authorized course of treatment; and
service has not expired. o The service was ordered by an authorized
provider; and
o The original authorization period for the
NH Healthy Families Member Services
1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 131

service has not expired.

To request continuation of benefits when the above conditions are met, contact:

NH Healthy Families
2 Executive Park Drive
Bedford NH, 03110
Attention: Grievance and Appeals
Fax Number: 866-270-9943

• If at your request the plan continues or reinstates your benefits while your appeal is
pending, your benefits must continue until one of the following occurs:

For standard and expedited plan appeals For standard and expedited State Fair
(first level appeal) Hearing appeals (second level appeal)
o You withdraw your plan appeal, in o You withdraw your State Fair Hearing
writing; or appeal request, in writing; or
o The plan’s first level appeal decision o You do not request a State Fair Hearing
results in an unfavorable decision for appeal AND continuation of benefits
you; or within 10 calendar days of the plan
notifying you of its first level appeal
o You do not request a State Fair Hearing
decision; or
AND continuation of benefits within 10
calendar days of the plan notifying you of o The State Fair Hearing appeal results in
its first level appeal decision. an unfavorable decision for you.

• If you lose your appeal and have received continued benefits, you may be responsible for
the cost of any continued benefits provided by the plan during the appeal period.

For help with your first and/or second level appeal and continuation of benefits, contact Member
Services (phone numbers are printed on the back cover of this handbook). You may also contact
the NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access
Relay: 1-800-735-2964), Monday through Friday, 8:00 a.m. – 4:00 p.m. ET.

For help with your second level appeal and continuation of benefits, contact the AAU at 1-800-
852-3345, extension 4292, Monday through Friday, 8:00 a.m. – 4:00 p.m. ET. You may also
contact the NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD
Access Relay: 1-800-735-2964), Monday through Friday, 8:00 a.m. – 4:00 p.m. ET.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 132

Section 10.7 How to file a grievance and what to expect after

you file

A grievance is the process a member uses to express dissatisfaction to the plan about any matter
other than the plan’s action as described in Section 10.1 (About the appeals process). You can
file a grievance at any time.

Types of grievances include:

• Dissatisfaction with the quality of care or services you receive;

• Dissatisfaction with the way you were treated by the plan or its network providers;
• If you believe your rights are not respected by NH Healthy Families or its network
providers; and
• Dispute of an extension of time proposed by the plan to make an authorization decision

To file your grievance:

• Call or write to NH Healthy Families. Writing is preferred (remember to keep a copy for
your records).
• You may designate someone to file the grievance for you, including your provider.
However, you must give written permission to name your provider or another person to
file a grievance for you. For more information about how to appoint another person to
represent you, refer to Section 2.13 (Other important information: You may designate an
authorized representative or personal representative).

Here is what you can expect after you file your grievance:

• NH Healthy Families will respond to your grievance as fast as your health condition
requires, but no later than 45 calendar days from the date the plan receives it. The
plan may take up to an additional 14 calendar days if you request the extension, or if the
plan needs additional information and feels the extension is in your best interest. If the
plan decides to take extra days to make the decision, the plan will tell you in writing. For
grievances about clinical matters, the plan will respond in writing. For grievances
unrelated to clinical matters, the plan may respond orally or in writing.
• You do not have the right to appeal your grievance. However, you have the right to voice
concerns to NH DHHS if you are dissatisfied with the resolution of your grievance.
Contact the NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447)
(TDD Access Relay: 1-800-735-2964), Monday through Friday, 8:00 a.m. – 4:00 p.m. ET.

For help with your grievance, contact Member Services (phone numbers are printed on the back
cover of this handbook).

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 133

This chapter was prepared by NH DHHS with adaptations from Know Your Rights: New
Hampshire Medicaid Managed Care Health Plans – Your Right to Appeal or File a Grievance, a
Disability Rights Center – NH ([Link]), version May 10, 2016.

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 134

Chapter 11. Ending your plan membership

Section 11.1 There are only certain times when your plan
membership may end

The times when your plan membership may end are:

• When you no longer qualify for New Hampshire Medicaid.

• If you decide to switch to another plan during the Annual Open Enrollment Period:

o When is the Annual Open Enrollment Period? This generally happens

November 1 through December 31 each year (dates may vary). NH DHHS will
mail you information to remind you about the Annual Open Enrollment Period.
The notice will provide instructions on how to switch health plans if you choose
to do so.

o When will your membership end? If you switch health plans during the Annual
Open Enrollment Period, your membership will end on December 31. The
effective date for your new plan coverage will be January 1 the following year.
For information on care transitions between plans, refer to Section 5.3 (Continuity
of care).

• If you request to be assigned to the same plan in which another family member is
enrolled.

• In certain situations, you may also be eligible to leave the plan at other times of the year
for cause. These situations include:

o When you move out of state.

o When you need related services to be performed at the same time and not all
related services are available within the network; and when receiving services
separately would subject you to unnecessary risk.

o For other reasons, such as poor quality of care, lack of access to services,
violation of your rights, or lack of access to network providers experienced in
dealing with your needs.

• You may also be eligible at other times of the year to leave the plan without cause,
including:

o During the 90 calendar days following the initial date of your enrollment with the
plan, or the date that NH DHHS sends you notice of enrollment, whichever is
later.

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 Member Handbook 135

o During the first twelve (12) months of enrollment for members who are auto-
assigned to a plan, and have an established relationship with a PCP that is only in
the network of a non-assigned health plan.

o During open enrollment related to NH DHHS’s new contracts for New Hampshire
Medicaid managed care plans.

o For 60 calendar days following an automatic reenrollment if the temporary loss of

Medicaid has caused you to miss the Annual Open Enrollment Period. (This does
not apply to new applications for New Hampshire Medicaid.)

• When NH DHHS grants members the right to terminate enrollment without cause and
notifies affected members of their right to disenroll from the plan.
• When members are involuntarily disenrolled from the plan as described in the next
section.

To request disenrollment from your plan, call or write to NH DHHS. Contact the NH DHHS
Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-
735-2964), Monday through Friday, 8:00 a.m. – 4:00 p.m. ET.

Until your new coverage begins you must continue to get your health care and prescription drugs
through our plan.

Section 11.2 When you may be involuntarily disenrolled

from the plan

There are times when a member may be involuntarily disenrolled from the plan, including:

• When a member has established out of state residence;

• When a member is ineligible for enrollment in the plan as established by NH DHHS;
• When a member uses their plan membership card fraudulently;
• Upon a member’s death; and
• Under the terms of the plan’s contract with NH DHHS, the plan may request a member’s
disenrollment in the event of the member’s threatening or abusive behavior that
jeopardizes the health or safety of other members, or plan staff or providers. If such a
request is made by the plan, NH DHHS will be involved in the review and approval of
such a request.

NH Healthy Families cannot ask you to leave the plan for any reason related to your health.

NH Healthy Families Member Services

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 Member Handbook 136

If you feel that you are being asked to leave the plan because of a health reason, contact the NH
DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access Relay:
1-800-735-2964), Monday through Friday, 8:00 a.m. – 4:00 p.m. ET.

NH Healthy Families Member Services

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 Member Handbook 137

Chapter 12. Legal notices

Many laws apply to this handbook and some additional provisions may apply because they are
required by law. This may affect your benefits, rights and responsibilities even if the laws are not
included or explained in this document.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Effective 07.01.2017

For help to translate or understand this, please call 1-866-769-3085.

Hearing impaired TTY 1-855-742-0123.

Si necesita ayuda para traducir o entender este texto, por favor llame al telefono.
1-866-769-3085. (TTY 1-855-742-0123).

Interpreter services are provided free of charge to you.

Covered Entities Duties:

NH Healthy Families is a Covered Entity as defined and regulated under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). NH Healthy Families is required by law to
maintain the privacy of your protected health information (PHI), provide you with this Notice of
our legal duties and privacy practices related to your PHI, abide by the terms of the Notice that is
currently in affect and notify you in the event of a breach of your unsecured PHI.

This Notice describes how we may use and disclose your PHI. It also describes your rights to
access, amend and manage your PHI and how to exercise those rights. All other uses and
disclosures of your PHI not described in this Notice will be made only with your written
authorization.
NH Healthy Families reserves the right to change this Notice. We reserve the right to make the
revised or changed Notice effective for your PHI we already have as well as any of your PHI we
receive in the future. NH Healthy Families will promptly revise and distribute this Notice
whenever there is a material change to the following:
• The Uses or Disclosures
• Your rights
• Our legal duties
• Other privacy practices stated in the notice

We will make any revised notices available on our website and through newsletter notifications.

NH Healthy Families Member Services

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 Member Handbook 138

Protecting Oral, Written and Electronic Personal Health Information (PHI)

NH Healthy Families protects your PHI. We have privacy and security processes to help. These
are some of the ways we protect your PHI:

• We train our staff to follow our privacy and security processes.

• We require our business associates to follow privacy and security processes.
• We keep our offices secure.
• We talk about your PHI only for a business reason with people who need to know.
• We keep your PHI secure when we send it or store it electronically.
• We use technology to keep the wrong people from accessing your PHI.

Permissible Uses and Disclosures of Your PHI:

The following is a list of how we may use or disclose your PHI without your permission or
authorization:

• Treatment - We may use or disclose your PHI to a physician or other health care provider
providing treatment to you, to coordinate your treatment among providers, or to assist us
in making prior authorization decisions related to your benefits.
• Payment - We may use and disclose your PHI to make benefit payments for the health
care services provided to you. We may disclose your PHI to another health plan, to a
health care provider, or other entity subject to the federal Privacy Rules for their payment
purposes. Payment activities may include:
o processing claims
o determining eligibility or coverage for claims
o issuing premium billings
o reviewing services for medical necessity
o performing utilization review of claims

• HealthCare Operations - We may use and disclose your PHI to perform our healthcare
operations. These activities may include:
o providing customer services
o responding to complaints and appeals
o providing case management and care coordination
o conducting medical review of claims and other quality assessment
o improvement activities

In our healthcare operations, we may disclose PHI to business associates. We will have written
agreements to protect the privacy of your PHI with these associates. We may disclose your PHI
to another entity that is subject to the federal Privacy Rules. The entity must also have a
relationship with you for its healthcare operations. This includes the following:
• quality assessment and improvement activities
• reviewing the competence or qualifications of healthcare professionals
• case management and care coordination
• detecting or preventing healthcare fraud and abuse.

NH Healthy Families Member Services

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 Member Handbook 139

• Group Health Plan/Plan Sponsor Disclosures – We may disclose your protected health
information to a sponsor of the group health plan, such as an employer or other entity that
is providing a health care program to you, if the sponsor has agreed to certain restrictions
on how it will use or disclose the protected health information (such as agreeing not to
use the protected health information for employment-related actions or decisions).

Other Permitted or Required Disclosures of Your PHI:

• Fundraising Activities – We may use or disclose your PHI for fundraising activities,
such as raising money for a charitable foundation or similar entity to help finance their
activities. If we do contact you for fundraising activities, we will give you the opportunity
to opt-out, or stop, receiving such communications in the future.
• Underwriting Purposes – We may use or disclosure your PHI for underwriting purposes,
such as to make a determination about a coverage application or request. If we do use or
disclose your PHI for underwriting purposes, we are prohibited from using or disclosing
your PHI that is genetic information in the underwriting process.
• Appointment Reminders/Treatment Alternatives - We may use and disclose your PHI to
remind you of an appointment for treatment and medical care with us or to provide you
with information regarding treatment alternatives or other health-related benefits and
services, such as information on how to stop smoking or lose.
• As Required by Law - If federal, state, and/or local law requires a use or disclosure of
your PHI, we may use or disclose your PHI information to the extent that the use or
disclosure complies with such law and is limited to the requirements of such law. If two
or more laws or regulations governing the same use or disclosure conflict, we will
comply with the more restrictive laws or regulations.
• Public Health Activities - We may disclose your PHI to a public health authority for the
purpose of preventing or controlling disease, injury, or disability. We may disclosure
your PHI to the Food and Drug Administration (FDA) to ensure the quality, safety or
effectiveness products or services under the jurisdiction of the FDA.
• •Victims of Abuse and Neglect - We may disclose your PHI to a local, state, or federal
government authority, including social services or a protective services agency
authorized by law authorized by law to receive such reports if we have a reasonable
belief of abuse, neglect or domestic violence.
• Judicial and Administrative Proceedings - We may disclose your PHI in judicial and
administrative proceedings. We may also disclose it in response to the following:
o an order of a court
o administrative tribunal
o subpoena
o summons
o warrant
o discovery request
o similar legal request.

NH Healthy Families Member Services

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 Member Handbook 140

• Law Enforcement - We may disclose your relevant PHI to law enforcement when
required to do so. For example, in response to a:
o court order
o court-ordered warrant
o subpoena
o summons issued by a judicial officer
o grand jury subpoena

We may also disclose your relevant PHI to identify or locate a suspect, fugitive, material witness,
or missing person.

• Coroners, Medical Examiners and Funeral Directors - We may disclose your PHI to a
coroner or medical examiner. This may be necessary, for example, to determine a cause
of death. We may also disclose your PHI to funeral directors, as necessary, to carry out
their duties.
• Organ, Eye and Tissue Donation - may disclose your PHI to organ procurement
organizations. We may also disclose your PHI to those who work in procurement,
banking or transplantation of:
o cadaveric organs
o eyes
o tissues
• Threats to Health and Safety – We may use or disclose your PHI if we believe, in good
faith, that the use or disclosure is necessary to prevent or lessen a serious or imminent
threat to the health or safety of a person or the public.
• Specialized Government Functions – if you are a member of the U.S. Armed Forces, we
may disclose your PHI as required by military command authorities. We may also
disclose your PHI:
o to authorized federal officials for national security
o to intelligence activities
o the Department of State for medical suitability determinations
o for protective services of the President or other authorized persons
• Worker’s Compensation - We may disclose your PHI to comply with laws relating to
workers’ compensation or other similar programs, established by law, that provide
benefits for work-related injuries or illness without regard to fault.
• Emergency Situations – We may disclose your PHI in an emergency situation, or if you
are incapacitated or not present, to a family member, close personal friend, authorized
disaster relief agency, or any other person previous identified by you. We will use
professional judgment and experience to determine if the disclosure is in your best
interests. If the disclosure is in your best interest, we will only disclose the PHI that is
directly relevant to the person's involvement in your care.
• Inmates - If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release your PHI to the correctional institution or law
enforcement official, where such information is necessary for the institution to provide

NH Healthy Families Member Services

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 Member Handbook 141

you with health care; to protect your health or safety; or the health or safety of others; or
for the safety and security of the correctional institution.
• Research - Under certain circumstances, we may disclose your PHI to researchers when
their clinical research study has been approved and where certain safeguards are in place
to ensure the privacy and protection of your PHI

Verbal Agreement to Uses and Disclosure of Your PHI— We can take your verbal agreement
to use and disclose your PHI to other people. This includes family members, close, personal
friends or any other person you identify. You may object to the use or disclosure of your PHI at
the time of the request. You can give us your verbal agreement or objection in advance. You may
also give it to us at the time of the use or disclosure. We will limit the use or disclosure of your
PHI in these cases. We limit the information to what is directly relevant to that person’s
involvement in your health care treatment or payment. We can take your verbal agreement or
objection to use and disclose your PHI in a disaster situation. We can give it to an authorized
disaster relief entity. We will limit the use or disclosure of your PHI in these cases. It will be
limited to notifying a family member, personal representative or other person responsible for
your care of your location and general condition. You can give us your verbal agreement or
objection in advance. You can also give it to us at the time of the use or disclosure of your PHI.

Uses and Disclosures of Your PHI That Require Your Written Authorization

We are required to obtain your written authorization to use or disclose your PHI, with limited
exceptions, for the following reasons:

Sale of PHI – We will request your written authorization before we make any disclosure that is
deemed a sale of your PHI, meaning that we are receiving compensation for disclosing the PHI
in this manner.

Marketing – We will request your written authorization to use or disclose your PHI for
marketing purposed with limited exceptions, such as when we have face-to-face marketing
communications with you or when we provide promotional gifts of nominal value.

Psychotherapy Notes – We will request your written authorization to use or disclose any of you
psychotherapy notes that we may have on file with limited exception, such as for certain
treatment, payment or healthcare operation functions.

Individuals Rights

The following are your rights concerning your PHI. If you would like to use any of the following
rights, please contact us using the information at the end of this Notice.

• Right to Revoke an Authorization - You may revoke your authorization at any time; the
revocation of your authorization must be in writing. The revocation will be effective
immediately, except to the extent that we have already taken actions in reliance of the
authorization and before we received your written revocation.

NH Healthy Families Member Services

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 Member Handbook 142

• Right to Request Restrictions - You have the right to request restrictions on the use and
disclosure of your PHI for treatment, payment or healthcare operations, as well as
disclosures to persons involved in your care or payment of your care, such as family
members or close friends. Your request should state the restrictions you are requesting
and state to whom the restriction applies. We are not required to agree to this request. If
we agree, we will comply with your restriction request unless the information is needed
to provide you with emergency treatment. However, we will restrict the use or disclosure
of PHI for payment or health care operations to a health plan when you have paid for the
service or item out of pocket in full.
• Right to Request Confidential Communications - You have the right to request that we
communicate with you about your PHI by alternative means or to alternative locations.
This right only applies if the information could endanger you if it is not
communicated by the alternative means or to the alternative location you want. You do
not have to explain the reason is for your request, but you must state that the information
could endanger you if the communication means or location is not changed. We must
accommodate your request if it is reasonable and specifies the alternative means or
location where you PHI should be delivered.
• Right to Access and Received Copy of your PHI - You have the right, with limited
exceptions, to look at or get copies of your PHI contained in a designated record set. You
may request that we provide copies in a format other than photocopies. We will use the
format you request unless we cannot practicably do so. You must make a request in
writing to obtain access to your PHI. If we deny your request, we will provide you a
written explanation and will tell you if the reasons for the denial can be reviewed and
how to ask for such a review or if the denial cannot be reviewed.
• Right to Amend your PHI - You have the right to request that we amend, or change, your
PHI if you believe it contains incorrect information. Your request must be in writing, and
it must explain why the information should be amended. We may deny your request for
certain reasons, for example if we did not create the information you want amended and
the creator of the PHI is able to perform the amendment. If we deny your request, we will
provide you a written explanation. You may respond with a statement that you disagree
with our decision and we will attach your statement to the PHI you request that we
amend. If we accept your request to amend the information, we will make reasonable
efforts to inform others, including people you name, of the amendment and to include the
changes in any future disclosures of that information.
• Right to Receive an Accounting of Disclosures - You have the right to receive a list of
instances within the last 6 years period in which we or our business associates disclosed
your PHI. This does not apply to disclosure for purposes of treatment, payment, health
care operations, or disclosures you authorized and certain other activities. If you request
this accounting more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests. We will provide you with more
information on our fees at the time of your request.
• Right to File a Complaint - If you feel your privacy rights have been violated or that we
have violated our own privacy practices, you can file a complaint with us in writing or by
phone using the contact information at the end of this Notice.

NH Healthy Families Member Services

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 Member Handbook 143

You can also file a complaint with the Secretary of the U.S. Department of Health and Human
Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201 or calling 1-800-368-1019, (TTY: 1-866-788-4989) or visiting
[Link]/ocr/privacy/hipaa/complaints/.

WE WILL NOT TAKE ANY ACTION AGAINST YOU FOR FILING A COMPLAINT.
• Right to Receive a Copy of this Notice - You may request a copy of our Notice at any
time by using the contact information list at the end of the Notice. If you receive this
Notice on our web site or by electronic mail (e-mail), you are also entitled to request a
paper copy of the Notice.

Contact Information
If you have any questions about this Notice, our privacy practices related to your PHI or how to
exercise your rights you can contact us in writing or by phone using the contact information
listed below.

NH Healthy Families
Attn: Privacy Official
2 Executive Park Drive
Bedford, NH 03110
1-866-769-3085
(TDD/TTY 1-855-742-0123)

Statement of Non-Discrimination
NH Healthy Families complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. NH Healthy
Families does not exclude people or treat them differently because of race, color, national origin,
age, disability, or sex.

NH Healthy Families:

• Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic
formats, other formats)

• Provides free language services to people whose primary language is not English, such
as:
o Qualified interpreters

NH Healthy Families Member Services

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 Member Handbook 144

o Information written in other languages

If you need these services, contact NH Healthy Families at 1-866-769-3085 (TDD/TTY 1-855-
742-0123.)
If you believe that NH Healthy Families has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with: Grievances and Appeals Coordinator, NH Healthy Families, 2 Executive Park
Drive, Bedford, NH 03110,1-866-769-3085 (TDD/TTY 1-855-742-0123), Fax 1-866-270-9943

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
NH Healthy Families is available to help you. You may also file a discrimination complaint
through the DHHS Office of the Ombudsman who has been designated to coordinate the efforts
of NH DHHS’s civil rights compliance for the Department: State of New Hampshire,
Department of Health and Human Services, Office of the Ombudsman, 129 Pleasant Street,
Concord, NH 03301-3857; (603) 271-6941 or (800) 852-3345 ext. 6941, FAX (603) 271-4632,
TDD Access: relay NH 1-800-735-2964; E-mail: ombudsman@[Link].
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint
Portal, Complaint forms are available at [Link] or by
mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue
SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697
(TDD).

NH Healthy Families Member Services

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 Member Handbook 145

NH Healthy Families Member Services

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 Member Handbook 146

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
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 Member Handbook 147

NH Healthy Families Member Services

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 Member Handbook 148

NH Healthy Families Member Services

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 Member Handbook 149

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.
 Member Handbook 150

NH Healthy Families Member Services

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 Member Handbook 151

Chapter 13. Acronyms and definitions of important words

Section 13.1 Acronyms

[Plans include other acronyms as appropriate.]

Acronym Description
AAC Augmentative Alternative Communication
AIDS Acquired Immune Deficiency Syndrome
APRN Advance Practice Registered Nurse
BiPAP Bilevel Positive Airway Pressure
BMI Body Mass Index
CMS Centers for Medicare and Medicaid Services
COBRA Consolidated Omnibus Budget Reconciliation Act (COBRA)
COPD Chronic Obstructive Pulmonary Disease
CPAP Continuous Positive Airway Pressure
DESI Drug Efficacy Study Implementation
DME Durable Medical Equipment
EOB Explanation of Benefits
EPSDT Early and Periodic Screening, Diagnostic and Treatment
ET Eastern Time
FDA Food and Drug Administration
FFS Fee-for-Service
FQHC Federally Qualified Health Center
HIV Human Immunodeficiency Virus
HNA Health Needs Assessment
IUD Intrauterine Device
IV Intravenous
LADC Licensed Alcohol Drug Counselor
LDCT Low Dose Computed Tomography
LPN Licensed Practical Nurse
LTC Long-term Care
MLADC Masters Licensed Alcohol and Drug Counselor
NEMT Non-emergency Medical Transportation
NH New Hampshire
NH DHHS New Hampshire Department of Health and Human Services
OB/GYN Obstetrics/Gynecology
OT Occupational Therapy
OTC Over-the-Counter (Drugs)
PCP Primary Care Provider (or Physician)
PAP Premium Assistance Program
PSA Prostate Specific Antigen

NH Healthy Families Member Services

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 Member Handbook 152

Acronym Description
PT Physical Therapy
RHC Rural Health Center
RN Registered Nurse
SBIRT Screening, Brief Intervention, and Referral to Treatment
ST Speech Therapy
STI Sexually Transmitted Infection
SUD Substance Use Disorder
TMJ Temporomandibular Joint

Section 13.2 Definitions of important words

Abuse – Abuse describes practices that, either directly or indirectly, result in unnecessary costs
to the Medicaid Program. Abuse includes any practice not consistent with providing members
with services that are medically necessary, meet professionally recognized standards, and are
priced fairly, as applicable. Examples of abuse include: billing for unnecessary medical services,
charging excessively for services or supplies, and misusing codes on a claim, such as upcoding
or unbundling billing codes.

Action – When the plan denies, reduces, suspends, or ends your health care service in whole or
in part. For more information about coverage decisions and other actions, refer to Chapter 10
(What to do if you want to appeal a plan decision or “action”, or file a grievance).

Advance Directive – Legal document that allows you to give instructions about your future
medical care. You can have someone make decisions for you if you are unable to do so for
yourself. Refer also to Section 9.3 (Advance care planning for your health care decisions).

Annual Enrollment Period – The time each year when you can change your health plan. This
generally happens November 1 through December 31 each year (dates may vary).

Appeal – Action taken if you disagree with the plan’s decision to deny a request for coverage or
payment. You may also make an appeal if you disagree with the plan’s decision to stop or reduce
services you are receiving. For more information, refer to Chapter 10 (What to do if you want to
appeal a plan decision or “action”, or file a grievance).

Authorization – Refer to the definition for “Prior Authorization”.

Authorized Representative or Personal Representative – A person to whom you give

authority to act on your behalf. The representative will be able to provide the plan with
information or receive information about you in the same manner that the plan would discuss or

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 Member Handbook 153

disclose information directly to you. For more information refer to Section 2.13 (Other important
information: You may designate an authorized representative or personal representative).

Balance Billing – When a provider bills a member more than the plan’s copayment amount, as
applicable, or charges a member for the difference between the provider billed amount and the
plan’s payment to the provider. As a plan member, you may only have to pay the plan’s
copayment amounts when you get covered prescriptions. We do not allow providers to “balance
bill” or otherwise charge you more than the amount of copayment your plan says you must pay.

Behavioral Health Emergency – An emergent situation in which the member is in need of

assessment and treatment in a safe and therapeutic setting, is a danger to themselves or others, or
exhibits significant behavioral deterioration rendering the member unmanageable and unable to
cooperate in treatment.

Behavioral Health Services – Another term used to describe mental health services and/or
substance use disorder services.

Benefit Year – The 12-month period during which benefit limits apply.

Brand Name Drug – A prescription drug made and sold by the company that developed the
drug. Brand name drugs have the same active ingredients as the generic version of the drug.

Care Coordination – The term used to describe the plan’s practice of assisting members with
getting needed services and community supports. Care coordinators make sure participants in the
member’s health care team have information about all services and supports provided to the
member, including which services are provided by each team member or provider. For more
information, refer to Section 5.2 (Care coordination support).

Centers for Medicare & Medicaid Services (CMS) – The federal agency that administers the
Medicare and Medicaid programs.

Continuity of Care – Refers to practices that ensure uninterrupted care for chronic or acute
medical conditions during transitions. For more information, refer to Section 5.3 (Continuity of
care).

Copayment – An amount you may be required to pay as your share of the cost for a medical
service or supply, including a doctor’s visit, hospital outpatient visit, or a prescription drug.
Under our plan, you may have a prescription drug copayment.

Cost-sharing – Cost-sharing refers to any copayment amount, deductible or out-of-pocket

maximum you may have to pay for a health care service or prescription drug. A member’s cost-
sharing is also known as the member’s “out-of-pocket” cost.

Coverage Decision – A determination or decision made by the plan about whether a service or
drug is covered. The coverage decision may also include information about any prescription
copayment you may be required to pay.
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 Member Handbook 154

Covered Services – Include all health care services, prescription drugs, supplies, and equipment
covered by our plan. New Hampshire Department of Health and Human Services rules (Chapters
He-W, He-E, He-C, He-M, and He-P) describe covered services under the plan. The rules are
available online at [Link] Refer to
the Benefits Chart in Chapter 4 for a list of covered services.

Disenroll or Disenrollment – The process of ending your membership in our plan.

Disenrollment may be voluntary (your own choice) or involuntary (not your choice).

Durable Medical Equipment (DME) – Certain equipment that is ordered by your doctor for
medical reasons. DME can typically withstand repeated use and is primarily and customarily
used to serve a medical purpose, and generally is not useful to a person in the absence of an
illness or injury, and is appropriate for use in the home.

Emergency Medical Care or Emergency Services – Treatment to address an emergency

medical condition. For more information, refer to Section 3.6 (Emergency, urgent, and after-
hours care).

Emergency Medical Condition – A “medical emergency” is when you, or any other reasonable
person with an average knowledge of health and medicine, believe that you have medical
symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss
of function of a body organ or part. The medical symptoms may be an illness, injury, severe
pain, or a medical condition that is quickly getting worse. Or in the case of a pregnant women in
active labor, meaning labor at a time when there is not enough time to safely transfer you to
another hospital before delivery, or the transfer may pose a threat to your health or safety or to
that of your unborn child.

Emergency Medical Transportation – Specialized transportation of a member to receive

emergency services as quickly as possible, such as in an ambulance.

Emergency Room or Emergency Department – An emergency facility department often

located within a hospital to treat medical emergencies.

Excluded Services – Refers to health care services and prescription drugs the plan does not
cover.

Fraud – Intentional deception or misrepresentation made by a person or business entity with the
knowledge that the deception could result in some unauthorized benefit to himself, some other
person, or the business entity.

Generic Drug – A prescription drug that has the same active-ingredient formula as a brand-
name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug
Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Granite Advantage – Beginning January 1, 2019, Granite Advantage replaces the New
Hampshire Health Protection Program (NHHPP) for eligible members. Impacted individuals will
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 Member Handbook 155

receive health insurance through the New Hampshire Medicaid Care Management program. The
State contracts with Medicaid managed care plans to provide health insurance coverage for
Granite Advantage members. Granite Advantage requires community engagement for members
between the ages of 19-64, unless otherwise exempted, to maintain health insurance coverage.
Community engagement requires that a person work, volunteer, or be engaged in other
qualifying activities for continued eligibility and health insurance coverage.

Grievance – The process a member uses to express dissatisfaction about any matter other than a
plan action. Grievances may include, but are not limited to, the quality of care or services
provided, and aspects of interpersonal relationships such as rudeness of a provider or employee,
or failure to respect the enrollee’s rights regardless of whether remedial action is requested.
Grievance includes an enrollee’s right to dispute an extension of time proposed by the plan to
make an authorization decision. For more information, refer to Chapter 10 (What to do if you
want to appeal a plan decision or “action”, or file a grievance).

Habilitation Services and Devices – Services and devices that help a person keep, learn or
improve skills and functioning for daily living. These services may include therapies and
services for people with disabilities that are delivered in a variety of outpatient settings.

Health Insurance – A type of insurance coverage that pays for medical, surgical, and other
health care expenses incurred by the insured (sometimes called a member). Health insurance can
reimburse the insured for expenses incurred from illness or injury, or pay the provider directly.

Home Health Aide – A home health aide provides services that do not need the skills of a
licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet,
dressing).

Home Health Care or Home Health Services – Services include part-time skilled nursing and
home health aide services, durable equipment and supplies, and therapies. For more information,
refer to the Benefits Chart in Chapter 4.

Hospice Services – Care for members at end of life, with a life expectancy of 6 months or less if
the illness runs its normal course.

Hospital Inpatient Stay or Hospitalization – A hospital stay when you have been formally
admitted to the hospital for skilled medical services. For more information, refer to the Benefits
Chart in Chapter 4 (Outpatient hospital services).

Hospital Outpatient Care – Medical care that does not require an overnight stay in a hospital or
medical facility. Outpatient care may be administered in a provider office or a hospital. For
example, most related services are provided in a provider office or outpatient surgery center.

Initial Enrollment Period – The timeframe when you are first eligible for enrollment in a
Medicaid managed care plan.

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 Member Handbook 156

List of Covered Drugs (Formulary or “Drug List”) – A list of covered prescription drugs.
The list includes both brand name and generic drugs.

Medicaid (or Medical Assistance) – Medicaid is a joint federal and state program that includes
health care coverage for eligible children, adults with dependent children, pregnant women,
seniors and individuals with disabilities.

Medically Necessary – Services, supplies, or prescription drugs needed for the prevention,
diagnosis, or treatment of a medical condition and meet accepted standards of medical practice.
For more information about medically necessary services, refer to Section 6.1 (Medically
necessary services).

Medicare – The federal health insurance program for people who are 65 years of age or older.
Others who can receive Medicare include people with disabilities under age 65 years, and people
with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis
or a kidney transplant).

Member (Member of our Plan, or “Plan Member”) – A person who is enrolled in our plan.

Member Services – A department in our plan responsible for answering your questions about
plan membership and benefits. (Phone numbers for Member Services are printed on the back
cover of this handbook).

Mental Health Crisis – Any situation in which a person’s behaviors puts them at risk of hurting
themselves or others and/or when they are not able to resolve the situation with the skills and
resources available. Many things can lead to a mental health crisis including, increased stress,
physical illness, problems at work or at school, changes in family situations, trauma/violence in
the community or substance use. These issues are difficult for everyone, but they can be
especially hard for someone living with a mental illness.

Network – The collective group of providers and facilities that are under contract with the plan
to deliver covered services to plan members.

Network Provider – Doctors, pharmacies and other health care professionals, medical groups,
hospitals, durable medical equipment suppliers, and other health care facilities that have an
agreement with the plan to accept our payment and your cost-sharing amount, if any, as payment
in full. We have arranged for these providers to deliver covered services to members in our plan.

New Hampshire Medicaid – The plan contracts with NH DHHS to provide managed care
services to individuals who are enrolled in New Hampshire Medicaid and select or are assigned
to our plan.

Non-Emergency Medical Transportation Services (NEMT) – These services are covered by

the plan if you are unable to pay for the cost of transportation to provider offices and facilities.
The plan covers non-emergency medical transportation to medically necessary New Hampshire

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 Member Handbook 157

Medicaid covered services listed in the Benefits Chart in Chapter 4 (Transportation services –
Non-emergency medical transportation (NEMT)).

Non-Participating Provider – Refer to the definition for “Out-of-Network Provider, Out-of-

Network Pharmacy or Out-of-Network Facility”.

Non-Preferred Drugs – A non-preferred drug is a drug which does not appear on the Preferred
Drug List (PDL).

Out-of-Network Provider, Out-of-Network Pharmacy or Out-of-Network Facility – A

provider, pharmacy or facility that is not employed, owned, or operated by our plan or is not
under contract to deliver covered services to plan members. Refer to Chapter 3 (Using NH
Healthy Families for covered services).

Out-of-Pocket Costs – Refer to the definition for “cost-sharing”.

Participating Provider – Refer to the definition for “Network Provider”.

Personal Representative – Refer to the definition for “Authorized Representative or Personal

Representative”.

Physician Services –Services provided by a licensed medical physician.

Plan – For purposes of this handbook, the term generally refers to a Medicaid managed care
organization contracted with NH DHHS to provide Medicaid managed care services to eligible
New Hampshire Medicaid beneficiaries.

Post-stabilization Care – Covered services, related to an emergency medical condition that are
provided after a member is stabilized to maintain the stabilized condition to improve or resolve
the enrollee’s condition.

Preauthorization – Refer to the definition for “Prior Authorization”.

Preferred Drugs List – The drugs on this list include both generic and brand name drugs
carefully selected by the plan with help from a team of doctors and pharmacists. The NH
Healthy Families’ List of Covered Drugs is called the “Preferred Drug List” (PDL).

Premium – The periodic payment paid to an insurance company or a health care plan by a
member or other party to provide health care coverage. There is no member premium for your
New Hampshire Medicaid managed care plan.

Prescription Drugs – Covered when filled at a network pharmacy.

Prescription Drug Coverage – The term we use to mean all of the drugs that our plan covers.

NH Healthy Families Member Services

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 Member Handbook 158

Primary Care Provider (PCP) – The network doctor or other provider you see first for most
health problems. He or she makes sure you get the care you need to keep you healthy. He or she
also may talk with other doctors and providers about your care. Refer to Section 3.1 (Your
Primary Care Provider (PCP) provides and oversees your medical care).

Prior Authorization – Approval in advance to get services or drugs. Some medical services or
drugs are covered only if your doctor gets prior authorization from the plan. Prior authorization
requirements for covered services are in italics in the Benefits Chart in Chapter 4.

Provider – Doctor or other health care professional licensed by the state to provide medical
services and care. The term “provider” also includes a hospital, other health care facility, and
pharmacy.

Quantity Limits – A tool to limit the use of selected drugs for quality, safety, or utilization
reasons. Limits may be on the amount of the drug that we cover for each prescription or for a
defined period.

Rehabilitation Services and Devices – Treatment or equipment you get to help you recover
from an illness, accident, or major operation.

Service Area – Health plans commonly accept or enroll members based on where the member
lives and the geographic area the plan serves. The service area for NH Healthy Families is
statewide.

Skilled Nursing Care – A type of intermediate care in which the member or resident of a
nursing facility needs more assistance than usual, generally from licensed nursing staff and
licensed nursing assistants.

Specialist – A doctor who provides care for a specific disease or part of the body.

Step Therapy – A requirement to try another drug before a health plan will cover the drug your
physician prescribed first.

Urgent Care or Urgently Need Care – Urgently needed services or after-hours care are
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires
immediate medical care to prevent a worsening of health due to symptoms that a reasonable
person would believe are not an emergency but do require medical attention. Urgently needed
services may be furnished by network providers or by out-of-network providers when network
providers are temporarily unavailable or inaccessible. Urgently needed services are not routine
care. For more information, refer to Section 3.6 (Emergency, urgent and after-hours care).

Waste – For purposes of this handbook, waste means the extra costs that happen when services
are overused or when bills are prepared incorrectly. Waste often occurs by mistake. For more
information, refer to Section 2.12 (How to report suspected cases of fraud, waste, or abuse).

NH Healthy Families Member Services

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NH Healthy Families Member Services

Method Member Services – Contact Information

CALL 1-866-769-3085

Calls to this number are toll-free. Normal business hours are

Monday-Wednesday 8am to 8pm and Thursday and Friday 8am to
5pm

Member Services also has free language interpreter services available

for non-English speakers.
TTY/TDD 1-855-742-0123 Relay 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.]

Calls to this number are free.

FAX 1-877-502-7255
WRITE NH Healthy Families
2 Executive park Drive
Bedford, NH 03110
WEBSITE [Link]

NH Healthy Families Member Services

1-866-769-3085 (TTY/TDD 1-855-742-0123)
Monday – Wednesday 8:00 a.m. to 8:00 p.m., Thursday - Friday 8:00 a.m. to 5:00 p.m.