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1. HOW LONG WILL FAMIS COVER MY CHILD?

FAMIS provides twelve months of continuous coverage (beginning with the month the child was enrolled), UNLESS:

• Your family’s gross monthly income goes over the income limit for your family size,
• The child moves out of Virginia,
• You apply for FAMIS Plus (children’s Medicaid) and the child is found eligible for FAMIS Plus,
• The child turns age 19 during the enrollment period, or
• You request, in writing, that the FAMIS coverage be stopped.

If none of the above changes happen, your child will remain covered by FAMIS for 12 months. Near the end of the 12 months, you will be sent a renewal application to complete in order to continue the FAMIS coverage for another year.

2. WHAT MUST I REPORT TO FAMIS?

You only have to report the following changes if they happen before your annual renewal:

A. INCOME – You must report an increase in your family income ONLY IF your increased gross monthly income (before any deductions) is over 200% of the federal poverty level (FPL) for your family size. If your gross monthly income goes up, but it is still less than or equal to the 200% FPL limit, you do NOT have to report it.

Number of persons in family	Monthly gross income limit * (200% FPL)
1	$1,805
2	$2,429
3	$3,052
4	$3,675
5	$4,299
6	$4,922
7	$5,545
8	$6,169
For each additional person, add	$ 624

* Effective January 23, 2009. NOTE: The income limits are adjusted annually.

How to use the chart -Count how many of your children and stepchildren under 19 years old live in your home. Add yourself if you are the parent or stepparent of the children. Add your husband or wife who lives in the home. For example, if you have 4 children and/or stepchildren under age 19 living in your home, and you live there with your husband, your family has 6 persons. The monthly income limit for 6 persons is $4,922. If your family’s gross monthly income goes over $4,922 a month, then you must report this to the FAMIS CPU. If your family has more than 8 members, add $624 for each additional person to the monthly income limit for 8 persons, ($6,169) to see the limit for your family size.

You do not have to report to us when your income goes down. However, you may want to report this if your children are in a managed care plan, because this may change the amount of the copayments that you have to pay for medical care, or your children may be eligible for FAMIS Plus (children’s Medicaid). FAMIS Plus does not require any co-payments.

B. CHANGE OF ADDRESS -You should always report any change in your address, so that we can contact you. You must report to us if your family, or one of the children in your family, moves out of Virginia.

C. ADDING CHILDREN TO YOUR FAMIS COVERAGE – You must contact FAMIS if you want to apply for coverage for a new baby, or for a child who has moved into your household. Please note: A signed application for a new baby must be received in the birth month or within three months following the month the baby is born to ensure that birth-related expenses will be covered if the baby is found eligible. You may fax your child’s application to FAMIS at 1-888-221-9402 or start the application process on line at www.famis.org. If you have questions, call FAMIS at 1-866-873-2647.

D. ADDING A PREGNANT WOMAN TO YOUR FAMIS COVERAGE – You must contact FAMIS if you want to apply for coverage for a pregnant woman in your household who is currently not covered by FAMIS. You may fax the application to FAMIS at 1-888-221-9402 or start the application process on line at www.famis.org. If you have questions, call FAMIS at 1-866-873-2647.

E. REQUEST TO CANCEL FAMIS – If your situation changes and you no longer want FAMIS for your children, we must have your request to cancel coverage in writing. Please FAX or mail your signed request to us. Our FAX number and mailing address are:

Mailing address: FAMIS

P.O. Box 1820

Richmond, VA 23218-1820 FAX number: 888-221-9402

Some reported changes require that the child’s eligibility for FAMIS be redetermined. If necessary, you will be sent a pre-filled FAMIS application. You will need to confirm that the information is correct, sign and return the form along with proof of the reported change.

3. ANNUAL RENEWAL OF FAMIS

You must renew your FAMIS coverage every year. You will be notified when it is time for renewal. You will be sent a pre-filled application to confirm that the information we have on record is still correct. When you receive the application, please review it to make sure that it is correct, add any information, sign it, attach proof of income and any other required documents, and return it by mail or fax. If you do not return the form on time, your child’s FAMIS coverage will be canceled.

Your child will be eligible for FAMIS for another 12 months if the child is still:

• Under 19 years of age;
• A resident of Virginia and a U.S. citizen, U.S. national, or a qualified immigrant;
• Living in a family with a gross monthly income that meets the income guidelines on page 2.
• Not insured by a health insurance plan (this does not include FAMIS MCO coverage or coverage under FAMIS Select).
• Not eligible for coverage under any State Employee Health Insurance Plan; and
• Not eligible for FAMIS Plus (children’s Medicaid).

4. HOW WILL MY CHILD RECEIVE SERVICES?

Once your child is enrolled in FAMIS, you will receive a permanent Commonwealth of Virginia health insurance card, one for each enrolled child in your household, unless the child was previously enrolled in FAMIS or FAMIS Plus (children’s Medicaid). If your child was enrolled in FAMIS or FAMIS Plus within the last 12 months, your child was sent a permanent Commonwealth of Virginia card and will not be sent another card. If you have lost the Commonwealth of Virginia card, you must call FAMIS and request a replacement card.

A. Your child’s health insurance card

If your child was not previously enrolled in FAMIS or FAMIS Plus, you will receive a plastic, permanent health insurance ID card from Commonwealth of Virginia. You will receive one card for each FAMIS enrolled child in your household. You will only receive one Commonwealth of Virginia health insurance card for your child, so do not lose or throw away the card. If your child is also enrolled in a managed care organization (MCO), he or she will also receive a separate identification (ID) card from the MCO.

It is your responsibility to show the child’s Commonwealth of Virginia health insurance card and the MCO ID card if you live in a MCO area to providers each time medical or dental services are received. You will also need to make sure the provider participates in the Family Access to Medical Insurance Security (FAMIS) program. Failure to present the card/s at the time of services may result in the parent or guardian being held responsible for any cost of the service. When you receive the child’s Commonwealth of Virginia health insurance card, check the information on it to be sure it is correct. If it is not correct, you must inform FAMIS of any needed changes or corrections.

Use the Commonwealth of Virginia health insurance card to get medically necessary care for your child and stop using the card immediately when notified by FAMIS that the child is no longer covered.

When your child is enrolled in a MCO, always show the child’s MCO ID card and the Commonwealth of Virginia health insurance card when receiving medical or dental services.

If you lose your child’s Commonwealth of Virginia health insurance card or it is stolen, call FAMIS for a replacement card. Never lend either the Commonwealth of Virginia card or the MCO ID card to anyone. If you lose your child’s MCO card, please call your child’s MCO.

B. Fee-for-Service

When a child is first enrolled in FAMIS, he or she is able to access health care through the FAMIS fee-for-service program. Children can see any provider in the FAMIS fee-for-service network. Before you schedule an appointment or before you get a prescription filled, ask the doctor, clinic, hospital, dentist, pharmacy or mental health provider if they accept FAMIS. Your child’s benefits will be similar to FAMIS Plus (children’s Medicaid) while in FAMIS fee-for-service. There are no co-payments in FAMIS fee-for-service.

Children who live in the following Virginia localities remain in the FAMIS fee-for-service program and continue to get health care from any FAMIS provider. These localities do not have a MCO available to provide services. If you live in one of these localities, you will not need to select a MCO:

Alleghany, Bath, Bland, Bristol, Buchanan, Carroll, Clifton Forge, Covington, Craig, Dickenson, Galax, Grayson, Highland, Lee, Norton, Russell, Scott, Smyth, Tazewell, Washington, and Wise.

Please contact FAMIS at 1-866-873-2647 for more information.

C. Managed Care Areas

If you live in a Virginia locality that is NOT listed in the above “Fee-for-Service” section, your child will be enrolled in a managed care organization (MCO). If you have not chosen a MCO for your child, please call FAMIS at 1-866-873-2647. If you do not choose a MCO, one will be chosen for your child. Your child will be enrolled in a MCO 1 or 2 months after FAMIS enrollment. During the 1 to 2 months before MCO enrollment, your child will get services through the FAMIS fee-for-service program. When enrolled in a MCO, your child must receive all care through a primary care provider (PCP). You must select a PCP from the network of PCPs available in your child’s MCO. That PCP will coordinate all of your child’s care within the MCOs network of providers, specialists and hospitals. While you will have a small-co-payment for services your child receives, you will also have additional benefits when you belong to a MCO. These benefits include case management, health education and disease management services, skilled nursing services, chiropractic care and a 24-hour nurse access telephone line.

Once your child is enrolled in the MCO, you will also receive a member ID card, a member handbook, and a provider directory from the MCO. This is in addition to the Commonwealth of Virginia health insurance card that you receive. You will only receive one MCO ID card and one Commonwealth of Virginia health insurance card for your child, so do not lose or throw away either card. The MCO ID card will include the name of the child’s PCP and telephone number, and the MCO’s identification number. If you lose your child’s MCO ID card, call the MCO to request a new one. Keep your child’s MCO ID card with his or her Commonwealth of Virginia health insurance card. Always show both your child’s MCO ID card and Commonwealth of Virginia health insurance card when your child receives medical or dental services.

If you are unhappy with your child’s PCP, you may call your child’s MCO at any time to change PCPs. If you are unhappy with your child’s MCO, you may call FAMIS to change to another MCO in the area. You must call within the first 90 days of enrollment with that MCO. After 90 days, your child will remain with that MCO until your child’s annual renewal. If you have questions, call FAMIS at 1-866873-2647.

When your child’s FAMIS coverage is renewed each year, you will have a chance to choose another MCO (if another is available in your locality) or remain with the current health plan. If you do not want to make a change, your child will remain with your current MCO.

There are five MCOs administering FAMIS in Virginia. Different MCOs serve different parts of Virginia. You may call FAMIS at 1-866-87FAMIS (1-866-873-2647) to find out which MCOs are offered in your area. If you are enrolled in a MCO and have questions or concerns about receiving services, contact your MCO at:

•

Amerigroup Community Care 1-800-600-4441

•

Anthem Healthkeepers Plus 1-800-901-0020

•

CareNet 1-800-279-1878

•

Optima Family Care 1-800-881-2166

•

Virginia Premier Tidewater Area 1-800-828-7989 Southwest/Western Area 1-888-338-4579 Richmond 1-800-727-7536

5. SMILES FOR CHILDREN

Your child’s dental services will be provided through the Smiles For Children program. There are no costs for dental care services in the Smiles For Children program. You can use your child’s plastic ID card from DMAS or your child’s MCO member ID card to get dental care for your child. You will receive a Smiles For Children member handbook from Doral Dental. The handbook will describe dental services that are covered. It will also list the Smiles For Children dentists. Call Smiles For Children at 1-888-912-3456 for questions about dental services or for help in finding a dentist or making a dental appointment.

6. WHAT DO I PAY FOR FAMIS?

FAMIS does not have yearly or monthly premiums. However, children who are enrolled in a MCO must pay co-payments for some covered services. There are no co-payments required for preventative services such as well-child care, immunizations, or dental care. The chart below shows the co-payment amounts for some basic FAMIS services for children who are enrolled in a MCO, based on co-pay status. Your co-pay status is on the letter you received from FAMIS, telling you that your child was approved for FAMIS coverage.

SERVICE	Co-pay Status 1	Co-pay Status 2
Outpatient Hospital or Doctor	$2 per visit	$5 per visit
Prescription Drugs	$2 per prescription	$5 per prescription
Inpatient Hospital	$15 per admission	$25 per admission
Non-emergency use of Emergency Room	$10 per visit	$25 per visit
Yearly Co-payment Limit per Family	$180	$350

NOTE: Native Americans and Alaskan Natives do NOT have any co-payments.

Other co-payments may apply to other services.

The FAMIS approval letter that you received also listed the amount of your yearly family co-payment limit. Whenever a child enrolled in FAMIS has a doctor’s appointment, needs a prescription filled or gets another FAMIS covered service, ask for and save the receipt that lists the co-payment amount.

Use the co-payment tracking form at the back of this handbook to record your family’s FAMIS co-payment expenses throughout your children’s twelve-month enrollment period. After you have reached the family copayment limit, send the completed form with copies of all the co-pay receipts to FAMIS for a co-payment review. Following the co-payment review, FAMIS will inform you if your family has reached the yearly copayment limit. Once it has been verified that your family has reached the yearly co-payment limit, no additional co-payments will be required for the remainder of your child’s twelve-months of coverage.

7. FAMIS SELECT – MAY HELP ME PAY FOR A PRIVATE HEALTH INSURANCE PLAN

Once you are enrolled in FAMIS, there is a special option available for families who have access to health insurance at work or prefer to purchase a private policy. It is called FAMIS Select.

A. What is FAMIS Select?

FAMIS Select is a program that gives parents of FAMIS approved children the freedom to choose between covering their children with the FAMIS health insurance plan or with a private or employer’s health plan. FAMIS Select gives parents that choose to purchase private or employer sponsored health insurance $100 per child per month to help pay the child’s part of the premium.

B. Why would a family choose to participate in FAMIS Select?

FAMIS Select may allow your child to continue to see a doctor or dentist that may not accept FAMIS. In some cases, a private or employer plan may give a family more choices of providers. For some families, the FAMIS Select payment will be enough to make health coverage affordable for the entire family. Remember, children in FAMIS Select get the health benefits through the private health plan their parents choose. It is important to compare health plans and choose the best plan for your family.

C. Who is eligible for FAMIS Select?

Any child who is approved for FAMIS and has access to a private or employer sponsored health plan is eligible to enroll in FAMIS Select.

D. How do I apply for FAMIS Select?

• Call FAMIS Select directly at 1-888-802-5437 or at 804-786-7024. FAMIS Select will mail you a packet that includes an application, instructions to complete the application and a program brochure.
• Applying for FAMIS Select is voluntary.
• You will be notified if your family is eligible for premium assistance through FAMIS Select, and how much your payment will be.
• If you are eligible for FAMIS Select and want to enroll, you will first enroll in your employer’s health insurance plan or in a private health plan at the first available opportunity, and then send FAMIS Select a copy of a pay stub showing that you are now paying for health insurance at work or send a copy of the payment slip indicating you are now paying for private insurance.

E. What should I expect if my children are enrolled in FAMIS Select?

• We will provide you with postage-paid envelopes to use to mail your pay stubs/payments to FAMIS

Select.

• At the end of the month, you will send a copy of your pay-stubs or payment slip to the Department of Medical Assistance Services FAMIS Select Unit.
• If your child is still eligible for FAMIS and you are still paying for health insurance at work or paying for private health insurance, you will be sent a check each month to reimburse you for the FAMIS child’s share of the cost of your health insurance premium. In some cases, the payment may be enough to cover the entire cost for family coverage. However, FAMIS Select will not pay for more than the total cost of your health care premium.
• You will use your employer’s plan or private plan first to receive services. You may use the FAMIS card for childhood immunizations if your health plan does not provide coverage.
• You are responsible for all co-payments and deductibles as required by your private or employer-sponsored health plan.
• To remain eligible for FAMIS Select, you must renew your FAMIS coverage every year. If you do not renew your coverage, FAMIS and FAMIS Select will be cancelled.

IF YOU ARE INTERESTED IN APPLYING FOR FAMIS Select, CALL TODAY! 1-888-802-KIDS (1-888-802-5437) or 804-786-7024

8. WHAT DO I DO IF AN ACCIDENT CLAIM MAY BE PAID BY OTHER INSURANCE?

FAMIS is designed to help children without comprehensive health insurance. Some types of accident, homeowners’, or school insurance plans may provide limited health insurance coverage. If a child receiving health care insurance through FAMIS is injured in any type of accident where another insurance company may pay for the child’s medical or dental treatment, the child’s parent(s) or guardian is required to inform the Department of Medical Assistance Services (DMAS) Third Party Liability Unit so that payment may be recovered from the other insurance company. The information needed includes: your name, your child’s name and ID number, your phone number with area code, the date services were received, the name of the other insurance company, the policy number, and the name of the attorney, if any. Send the information to the following address:

Third Party Liability Unit Dept. of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA 23219

If the insurance company pays you after FAMIS has paid the same bill, you must also notify the Department of Medical Assistance Services (DMAS) Recovery Unit at the following address:

Recovery Unit Dept. of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA 23219

When FAMIS has paid for services and it is later found another payment source was available, attempts will be made to recover the money from the other source.

9. WHAT SERVICES DOES FAMIS COVER?

The services listed below (in alphabetical order) are covered by FAMIS. Certain other services may be covered within limitations. Some exceptions may apply.

Abortion Services -FAMIS covers abortions only if necessary to save the life of the mother.

Ambulance -FAMIS covers ambulance services for emergencies when used locally to transport to or from a medical facility or provider’s office.

BabyCare -FAMIS covers a case management program for pregnant women or children up to the age of two who may be at higher risk for problems during the pregnancy or early childhood. If you are enrolled in Fee-for-Service FAMIS, please contact 804-786-6134 for more information. If you are enrolled in an MCO, please contact your MCO for additional information.

Clinic Services -FAMIS covers these services when they are provided by health centers or by other ambulatory health care centers.

Community Mental Health Rehabilitative Services -Community Mental Health Services include community rehabilitation mental health services, including intensive in-home services, case management services, day treatment, and 24-hour emergency response. The Department of Medical Assistance Services (DMAS) pays for these services.

Dental Care Services -FAMIS covers diagnostic, preventive and primary services, as well as complex restorative dental services such as dentures, inlays, on lays, crowns, and relining dentures for a better fit. Orthodontic services are also covered. Some services require pre-authorization. This program is called

Smiles For Children.

*Durable Medical Supplies and Equipment -FAMIS covers durable medical equipment and other medically related or remedial devices. Included are prosthetic devices, implants, hearing aids and adaptive devices.

Early Intervention Services -FAMIS covers medically necessary speech, physical and occupational therapies and assistive technology from birth to age 3 if certified by the Department of Mental Health Mental Retardation and Substance Abuse Services under Part C of the Individuals with Disabilities Education Act (IDEA).

Home and Community-Based Health Care -FAMIS covers nursing services, home health aides, physical therapy, occupational therapy, and speech, hearing and inhalation therapy.

Hospital Care -FAMIS covers 365 days per confinement in a semi-private room or intensive care unit. Ancillary charges are included. Hospital admissions must be pre-authorized.

Hospital Emergency Services – FAMIS covers emergency room treatment and services for life-threatening conditions.

Hospice Services -FAMIS covers home and inpatient care for terminally ill patients expected to live no more than six months, as certified by a physician.

*Inpatient Mental Health Services-FAMIS covers services furnished in a psychiatric unit of a general acute care hospital.

Laboratory and X-ray Services -FAMIS covers outpatient diagnostic tests, X-rays, and laboratory services when performed in a physician’s office, hospital, independent or clinical reference lab.

*Nursing Services -FAMIS covers the services of a nurse practitioner, nurse midwife, advanced practice nurse, pediatric nurse and respiratory care services in a home or other setting.

Outpatient Care -FAMIS covers outpatient services including emergency services, surgical services and professional services provided in a physician’s office or outpatient hospital department.

Outpatient Mental Health Services – FAMIS covers services furnished in a community-based setting. Medically necessary visits with a licensed mental health professional are covered each benefit period. Services must be pre-authorized.

Physician’s (Doctor’s) Services -FAMIS covers physician’s services received while hospitalized, or in a physician’s office, or in an outpatient hospital department.

Prenatal Care, Family Planning Services -FAMIS covers maternity care services. Coverage also includes drugs, supplies, and devices provided under the supervision of a physician to prevent pregnancy.

Prescription Drugs Ordered by a Physician -FAMIS covers outpatient prescription drugs. Prescriptions must be filled using a generic drug. If you choose the brand when a generic is available, you are responsible for the co-payment plus 100% of the difference between the allowable charge of the generic drug and the brand drug.

Rehabilitation Services -FAMIS covers physical, occupational and speech-language pathology for individuals with speech, hearing and language disorders. Pre-authorization is required.

Surgical Services -FAMIS covers surgical services provided during a hospital admission, or in a physician’s office or in an outpatient hospital department.

Services for Special Education Students -FAMIS covers physical therapy, occupational therapy, speech language pathology, psychological services and skilled nursing services for students who have these needs documented in their Individualized Education Program (IEP).

Transplantation Services -FAMIS covers major organ transplants includes heart, liver, pancreas/kidney, lung and heart/lung. Transplants of tissues, certain antilogous, allogenic or syngeneic bone marrow transplants (or other forms of stem cell rescue) are also covered when pre-authorized.

*Vision Care -FAMIS covers routine eye examinations every 24 months, eyeglasses and medically necessary contact lenses.

Well-Child Care -FAMIS covers well-child visits for children from birth through 18 years of age including visits, laboratory services, and any immunizations recommended by the Advisory Committee on Immunization Practice (ACIP) or the American Academy of Pediatric Advisory Committees. Also includes lead screening.

* See the managed care organization’s member handbook for specific information on the above covered services that are marked with *. If your child is not enrolled with a managed care organization, call the DMAS Helpline number 1-804-786-6145 for more information about covered services.

10. OUT-OF-STATE MEDICAL COVERAGE

FAMIS enrollees in fee-for-service: FAMIS covers emergency medical services while an enrolled child is temporarily outside of Virginia, if the provider of care agrees to participate in Virginia’s FAMIS/Medicaid program and to bill DMAS for the services provided. FAMIS does not cover medical care rendered outside of the United States.

FAMIS enrollees in managed care organizations (MCOs): MCOs cover emergency medical services while an enrolled child is temporarily outside of Virginia, if the provider of care agrees to bill the MCO and accepts the MCO reimbursement for the services provided. The provider should contact the enrollee’s MCO. MCOs do not cover medical care rendered outside of the United States.

11. OTHER PROGRAMS AND SERVICES

Emergency Services Medicaid – Contact your local Department of Social Services information about emergency services.

FAMIS MOMS – Provide enrollees the same coverage that pregnant women currently receive from the Virginia Medicaid program. FAMIS MOMS expands this coverage to include pregnant women with family incomes over 133% but less than or equal to 185% of the Federal Poverty Guidelines.

FAMIS Plus -Is the Medicaid program for children whose incomes are at or below 133% of the Federal Poverty Guidelines. The local Department of Social Services in the city/county you reside maintains your case.

FAMIS Select – Gives families of FAMIS-eligible children the opportunity to choose between coverage under FAMIS and coverage through a private or employer-sponsored health plan. Children enrolled in FAMIS Select access health insurance through their private or employer-sponsored health plan and will present the identification card of that plan for payment. Children enrolled in FAMIS Select do not have access to direct FAMIS coverage except if needed to cover childhood immunizations.

Smiles For Children – Is Virginia’s dental program for children enrolled in Medicaid, FAMIS and FAMIS Plus. See page 8 for covered services.

WIC – Is a supplemental food and nutrition education program for pregnant, postpartum, or breastfeeding women; infants (from birth to 11 months); and children under five. WIC provides vouchers for the purchase of specific nutritious foods and nutrition counseling. Your child’s doctor must refer your child to the local health department for a WIC eligibility determination. Contact your local health department for more information.

12. WHAT DO I DO IF I HAVE A COMPLAINT?

If you have a complaint about FAMIS, you may call the FAMIS Central Processing Unit at 1-866-87FAMIS (1-866-873-2647).

If you have a complaint about a managed care organization (MCO), when your child is enrolled in a MCO, call or write to the MCO. You will find more information about filing complaints and requesting a review of MCO decisions (appeals) in the handbook that you will receive from your selected MCO.

If you have a complaint about a doctor, pharmacy, or hospital when your child is NOT enrolled in a MCO, you

must write to:

Medical Support Unit

Department of Medical Assistance Services

600 East Broad Street, 12^th Floor

Richmond, Virginia, 23219

If your complaint is about a health treatment matter, a decision must be made within 72 hours.

After review by the MCO or the Medical Support Unit, you will have an opportunity for a final independent review. You will be given information about the final independent review when the MCO or Medical Support Unit has completed its review process.