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Getting the most from my coverage. It's all part of my plan.

Get the Most from Your Coverage

Your Child Deserves Quality Healthcare. And you also deserve to have the information you need to get the most from your child’s coverage. Goals for quality are set and reviewed by CMS Health Plan to make sure your child gets the proper care.

This information is part of a Quality Program designed to improve the services and care your child gets. It provides details about the coverage and services available. 

Contact Member Services to learn more about the Quality Program.

Know Your Rights

Being a member means there are things you should expect from CMS Health Plan. These are some of your rights:

  • Your child should be treated with courtesy and respect
  • You should be able to get a copy of your child’s medical record
  • You should know your child’s medical data will be kept private. There are policies in place to guard health records and protected health information.

It’s also important to know what you can do to get the most from your coverage:

  • Ask questions if you don’t understand your rights
  • Be sure to keep your child’s scheduled appointments
  • Keep your child’s Member ID Card with you so you have it at appointments
  • Tell your child’s doctor if your child has gotten care in an emergency room.

The full list of rights and responsibilities is in your Member Handbook.

Getting the Care Your Child Needs

The PCP is the doctor your child will see for routine checkups and care. The PCP will help find other types of healthcare providers if your child needs one. You can also search Find-a-Provider on the CMS Health Plan website <or mobile app>.

As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call CMS Health Plan if you need help finding an adult provider.

You should be able to schedule an appointment with your child's PCP and get medical care when your child needs it. It may take a little longer to get in to see certain other types of providers, like specialists. Call CMS Health Plan if you can’t get an appointment in a timely manner.

Your child should get high quality medications and the right treatment for his or her conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on the CMS Health Plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to a doctor or pharmacist to review the PDL and answer questions about your child’s medications.

The Utilization Management (UM) Department looks at your child’s health records and may also talk with your child’s doctor to decide if a service he or she needs is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:

  • If the service is medically necessary
  • If the service works well
  • If the service is right for your child

New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by CMS Health Plan. Your child’s plan covers care that is medically necessary. Not every new medical service is covered for all members.

If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to the request, condition and benefits.

Get More Information

The Member Handbook is a great source for information about coverage and benefits. It also lists important phone numbers.

Contact Member Services for additional help at 1-866-799-5321 (TTY 1-800-955-8770). Translation services are available if you need them.

Contact Member Services to get:

  • A paper copy of your Member Handbook, Privacy Notice or anything on the CMS Health Plan website
  • Help finding a doctor and making an appointment
  • Help speaking with your child’s care manager
  • Help with an appeal for a service that’s been denied
  • Help with a ride to your child’s appointment

The CMS Health Plan website also has a lot of helpful information. Visit it to find the Member Handbook, Find-a-Provider tool, and the Preferred Drug List

Creating an online member account is free and easy. With it, you can:

  • Find or change your child’s PCP
  •  Request a new Member ID Card or print a temporary ID Card
  • View and update your child’s personal information

You can also send a message directly to CMS Health Plan from a member account.