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Medicaid 12 Tips

How to make the most of your health plan

  1. Know your rights and learn about the health plan’s quality program.

    To review your rights and responsibilities as a health plan member and to learn about the health plan’s quality program and goals, please visit your health plan’s website. If you would like a written copy of our quality program or a copy of your Rights and Responsibilities, please call Member Services. You may also find a written copy of the Rights and Responsibilities document in the Quality section of your health plan’s website.

  2. Read your Member Handbook.

    Your Member Handbook (PDF) is a good source of information. The documents help you understand:

    • The benefits and services you have and don’t have (exclusions)
    • How to get your prescription drugs and what drugs are covered
    • How to select a primary care provider (PCP)
    • What to do if you need care when you are out of town
    • How to voice a complaint or appeal a coverage decision
    • How to get care from specialists, hospitals and mental health providers
    • And more
  3. Find out how to use your pharmacy benefit.

    If your medicines are included on the Preferred Drug List (PDL) or Formulary, you’re all set. If your prescriptions aren’t on the PDL, schedule an appointment with your doctor. They may be able to help you switch to a drug that is on the PDL. Your doctor can also help you ask for an exception if they think you need a medicine that’s not on the list. View the PDL. You can also call Member Services.

  4. Find out about charges you may be responsible for.

    It’s very important that you follow the rules when getting medical care so you’re not billed for services. You must get care from the doctors and other medical providers listed in the Health Plan of Nevada Provider Directory. You must get a referral from your PCP to see a specialist or get certain services. The only exception is during a medical emergency.

    It is also important to know your benefits. If you get medical care that’s not a Medicaid benefit, you may be billed for those services. For example, if you pick a pair of glasses that cost more than the benefit, you’ll need to pay the difference.

    Services received outside the country are not covered Medicaid benefits. Health Plan of Nevada will not pay for these services. You may also get a bill for medical care your newborn receives, if you don’t tell your caseworker you had a baby.

  5. Know what to do if you have an issue and how to submit a complaint.

    We strive to meet your needs. If you are unhappy with services or care, or with the health plan in general, please call Member Services or write a letter to Health Plan of Nevada. Either way, we will respond to your issue.

  6. Know how to get information at your fingertips such as how to pick and make an appointment with a provider, how to get specialty and behavioral health care services and which hospitals are on our plan.

    Did you know your health plan has online tools to help you? You can search our online provider directory and review the drugs covered on our drug list. As a member, you also get information on our programs and services, such as health education and wellness classes and value added services. As always, if you have questions about your plan, call Member Services.

  7. Know that we research new medical technology.

    For safety reasons, we formally evaluate new and emerging medical discoveries before including them in our member benefit package. Led by a highly skilled staff that includes physicians, our review process compares new technology to medical standards and clinical research to measure the effectiveness and safety of new medical procedures, drugs and devices. We also research new applications of existing technologies. If you, your providers or other interested parties would like to submit a request for the review of new medical technology, please contact Member Services.

  8. Ask for help if you speak another language.

    If you need help with communication, such as the services of a language interpreter, please call Member Services.

  9. Know that the health plan does not offer incentives for prior authorization denials.

    Health Plan of Nevada prohibits the compensation of physicians, other health care professionals or staff to be based upon or used as an incentive for the denial of benefits. All decisions regarding your benefits are given special consideration based on your medical needs and the appropriateness of the care and service. Health Plan of Nevada employees who perform utilization review duties do not receive any incentives, financial or otherwise, to encourage denial of benefits. That is, we provide no incentive for anyone on our team to restrict benefits for our members. For more information, please call Member Services.

  10. Learn about internal and external review for denial of benefits.

    If a benefit is denied, we provide internal review to help ensure member satisfaction. Additionally, a review is provided by a panel of medical professionals from outside of Health Plan of Nevada for eligible denials that have already undergone internal review. Expedited (rush) appeals are available when decisions are needed quickly. For additional information, please refer to your Member Handbook.

  11. Know that we have special programs available for members.

    Are you looking for extra help? You may be eligible for additional benefits from one of these programs.

    Disease Management: If you have diabetes or asthma, you may be eligible to receive educational materials and calls from a Registered Nurse Health Coach. For more information, call the Disease Management Program at 1-877-692-2059, TTY 711 on weekdays between 8 a.m. and 5 p.m. PST.

    Case Management: This program provides additional assistance for members with extra special needs. For more information, contact Member Services.

    Members are randomly selected for these surveys. If you get one, please fill it out. Your input is valuable to us.

  12. Find out what to do if you have an emergency, are out of the area, need care after hours, and any benefit limitations or additional costs.

    The Health Plan of Nevada service area covers Clark and Washoe Counties. When you are out of the service area during an emergency, you should seek attention at the nearest urgent care center or hospital emergency room. Make sure you tell them you are a Health Plan of Nevada member.

    Hospital emergency rooms are there to offer emergency treatment for trauma, serious injury and life-threatening symptoms. Health Plan of Nevada covers any emergency care you need throughout the United States and its territories. Within 24 hours after your visit, call Member Services at 1-800-962-8074, TTY 711.

    If you are outside of the United States and need medical care, any health care services you receive will not be covered by Health Plan of Nevada. Medicaid cannot pay for any medical services you get outside of the United States. For additional information, please refer to your Member Handbook (PDF).

Questions about your plan?

Call Member Services at 1-800-962-8074.