What is ACCESS Plus?

ACCESS Plus is a health care delivery system in which you will choose a primary care provider (also called a “PCP”). You will get most of your medical care from your PCP. If you need to see a specialist, you will need a referral from your PCP.

How do I pick or change my PCP?

If you need to pick a PCP or change the one you have, please call the Enrollment Services Hotline at 1-800-485-5998. Staff will give you the names and addresses of other doctors in your area. Or, you can ask for a list of Medical Assistance (MA) providers and we will mail one to you. To get a list sent to you, call the ACCESS Plus toll-free Helpline at 1-800-543-7633. You can pick your new PCP from this list.

You can also search for a provider on-line.

When you change your PCP, a new ACCESS Plus ID card will be sent to you. The new PCP will become your doctor the first day of the next month.

Does everyone in my family have to pick the same PCP?

No. There are several kinds of providers who may be PCPs:

• Family practice and general practice doctors (who treat adults and children).
• Internal medicine doctors (who only treat adults).
• Pediatricians (who only treat children and teens).
• Medical residents.
• Certified registered nurse practitioners.
• Certified registered midwives.
• Physician’s assistants.
• Physician specialists.

You can pick one PCP for the whole family. Or, you can pick a PCP for yourself and a different one for your children. You may also be able to pick a specialist as a PCP if you already get care from them. For example, a pregnant woman may want to pick her OB/GYN as her PCP.

Will I need a PCP referral to get all of my other health care services?

When your PCP sends you to see a specialist, it is called a “referral”. You will need a referral to get some services, but not others. The cost of the visit to the specialist may not be covered IF you do not call your PCP first.

What services do I need a referral for?

If you get any of these services with a referral, you will not have to pay a bill:

• Ambulatory surgical center.
• Hearing (audiology) for those under 21 years of age only.
• Case management for those under 21 years of age only.
• Hospital-rehab (outpatient).
• Independent medical/clinical/surgical center.
• Personal care (under 21 only).
• Physician services except OB/GYN.
• Foot doctor (podiatrist) services.

You do not have to pay for covered services you get from a MA provider. If you get a bill for covered services, please call the ACCESS Plus Helpline at 1-800-543-7633.

What services do I not need a referral for?

Not all specialty services need a referral. You do not need a referral for these services. You will not have to pay a bill IF you go to any of the following:

• MA provider.
• Family planning.
• Pregnancy related services.
• OB/GYN treatment.
• Dental services.
• Eye exams.
• Medical services through the school.
• Mental health services.
• Drug or alcohol treatment.
• Inpatient hospital care.
• Hospice.
• Nursing home or residential care in a medical facility.
• Medical transportation or ambulance.
• Prescriptions.
• True emergency services.
• Diagnostic/laboratory services (like X-rays or blood work).
• Medical equipment.
• Help to stop smoking.

You do not have to pay for covered services you get from a MA provider. If you get a bill for covered services, please call the ACCESS Plus Helpline at 1-800-543-7633.

What do I do if there is an emergency?

An emergency is a health problem that is life threatening or one that will seriously affect your health if not treated right away. It can result from an accident or sudden illness and puts you in danger of death or severe harm. If you have an emergency, approval for care is NOT needed. Call 9-1-1 or go to the nearest emergency room.

Some examples of emergencies are:

• Chest pain.
• Poisoning.
• A serious accident.
• Severe burns.
• Damage to your eyes.
• Broken bone(s).
• Throwing up blood.
• Sudden loss of feeling or not being able to move.
• Severe pain in your stomach area.
• Fainting or a severe dizzy feeling.
• Severe wound or heavy bleeding.
• Choking or being unable to breathe properly.
• Severe shortness of breath.
• Miscarriage (when a pregnant woman loses her baby).
• Strong feeling you might kill yourself or another person.

What is E.P.S.D.T.?

E.P.S.D.T. stands for Early and Periodic Screening, Diagnosis, and Treatment. It also stands for Every Parent Should Do This. E.P.S.D.T is a free health care program for kids, teens, and young adults through age 20 who use the ACCESS card.

An EPSDT check-up includes:

• Complete physical exam.
• Hearing test.
• Vision test.
• Developmental screening.
• Lab work (blood and urine tests).
• Immunizations (shots that stop sickness).
• Complete health history and education on staying healthy.

Call our toll-free Helpline at 1-800-543-7633 and we will:

• Schedule an EPSDT check-up.
• Help with transportation.
• Remind you when the next EPSDT check-up is due.

If a problem is found during the EPSDT check-up, your PCP can refer you to a specialist. Those under the age of 21 may be able to get things like a hearing aid, eyeglasses, and braces for teeth.

What about behavioral health services?

ACCESS Plus will only affect how you get your physical health care. If you need mental health treatment, you should contact your county’s MH/MR program. If you need drug or alcohol treatment, you should contact your county’s Drug and Alcohol Program.

Call our toll-free Helpline at 1-800-543-7633 if you need help getting these services.

What is disease management?

If you have been diagnosed with one of these diseases, you will be able to get “disease management” services:

• Asthma.
• Diabetes (sugar).
• Chronic Obstructive Pulmonary Disease (COPD).
• Coronary Artery Disease (CAD).
• Congestive Heart Failure (CHF).

Disease management helps you best manage your disease and stay as healthy as possible. Participation in Disease management is voluntary.

Call the toll-free ACCESS Plus Helpline at 1-800-543-7633 if you need help or have questions.

Does everyone on Medical Assistance (MA) have to join ACCESS Plus?

No. Some people will not be enrolled in ACCESS Plus. These are:

• People who are in an MA Voluntary Managed Care Organization (MCO).
• People in the Health Insurance Premium Payment (HIPP) Program who are in an HMO.
• People over the age of 21 who have MA and Medicare.
• People who live in a nursing home.