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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 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 child’s coverage:

  • Ask questions if you don’t understand your and your child’s 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.

View the full list of rights and responsibilities in the CMS Health Plan Member Handbook.

We are committed to keeping your child’s race, ethnicity, and language (REL), and sexual orientation and gender identity (SOGI) information confidential. We use some of the following methods to protect your child’s information: 

  • Maintaining paper documents in locked file cabinets
  • Requiring that all electronic information remain on physically secure media
  • Maintaining your electronic information in password-protected files

We may use or disclose your child’s REL and SOGI information to perform our operations. These activities may include: 

  • Designing intervention programs
  • Designing and directing outreach materials
  • Informing health care practitioners and providers about your language needs
  • Assessing health care disparities

We will never use your child’s REL and SOGI information for underwriting, rate setting or benefit determinations or disclose your child’s REL or SOGI information to unauthorized individuals.

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. Your child may have to wait 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.

Interpreter services are provided free of charge to you when talking with your health plan or doctors and during the grievance process. This includes American Sign Language and real-time oral interpretation by certified medical interpreters. Our interpreters have demonstrated proficiency in both English and the non-English language of the member. 

If you need something translated into a language other than English, please call CMS Health Plan at  1-866-799-5321 (TTY: 1-800-955-8770). We can also provide materials in other formats such as Braille, CD or large print. 

Your child should get high-quality medications and the right treatment for their conditions. But not all drugs are covered and some may need to be approved before they’re covered. Find the Preferred Drug List (PDL) on the Pharmacy page. It is updated regularly and lists drugs that are covered by CMS Health Plan. Talk to a doctor or pharmacist to review the PDL and ask 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 they need 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

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

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If you have questions, reach out to your child’s Care Manager. You may also call Member Services for help at 1-866-799-5321 (TYY 1-800-955-8770). Someone is available Monday through Friday, 8 a.m. to 8 p.m. Eastern. Translation services are available if you need them.

Member Services can provide:

  • 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

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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

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Creating an online member account is free and easy:

  • Login
  • On the dropdown, select ‘Member’ and Children’s Medical Services Health Plan before selecting submit.
  • Once you’re on the official login page, select ‘Create New Account’.
  • Fill out the fields, then select ‘Create Account’.

Within your online account, 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
  • Send a message directly to CMS Health Plan