Member Handbook - McLaren
McLaren Healthy Michigan Plan Member HandbookMHPHM20140230Member HandbookRevised 1/2015G-3245 Beecher Rd. Flint, Michigan 48532-1511 (888) 327 0671 Fax (877) 502 1567January 2015
MHP Medicaid Member HandbookMcLaren Health PlanHealthy Michigan Member HandbookTABLE OF CONTENTSWelcome .Your Rights .Your Duties .Patient Advocate and Advance Directive .How to Get Medical Care.Do I Need a Referral?.Special Needs .Healthy Behaviors .Co-Pays .Services Covered by Medicaid .Services Not Covered .Services Covered by MHP .Most Often Asked Questions about Covered Services Doctor Services. Durable Medical Equipment . Emergency Care and Urgent Care . Eye Care . Family Planning . Health Education . Hospice . Hospital Care . Lab, X-ray and Tests . Other Services. Out of Area Care. Pregnancy . Preventive and Wellness Service and Chronic Disease Management . Rehabilitative and Habilitative Services and Devices . Tobacco Cessation Treatment . Transportation . When You Need a Medication . Women’s Routine and Preventative Health Services .Member Complaint/Grievance and Appeals .Fair Hearing Process .For Your Information . New Medical Care. Website . When Your Family Size Changes . Physicians Payments and Incentives . Beneficiary Monitoring Program . Fraud and Abuse .Privacy Notice .(888) 1212121213131313141414141515161818181919191920201
WelcomeWelcome to McLaren Health Plan. McLaren Health Plan (MHP) will help you get your healthcare. When you join McLaren Health Plan, each family member should pick a primary careprovider from our list of doctors. This will be your primary care provider. If for some reasonyou do not choose a doctor, McLaren Health Plan will help you pick one close to your home. Ifyou do not like who we chose, you can call Customer Service at (888) 327-0671.This Member Handbook gives you helpful tips about McLaren Health Plan and yourHealthy Michigan benefits. Please read this book and keep it in a safe place in case youneed it again.Your MHP Healthy Michigan Identification CardYou will have two identification cards (ID cards). One is for MHP and the other for Medicaid.The Medicaid card is plastic and has “mihealth” written on it. You will get a regular plasticMedicaid card from the State to use for services you still get through Medicaid. Call Medicaid at(800) 642-3195 if you did not get a plastic Medicaid card or if you have a question about theservices Medicaid will cover.If there is a mistake on your MHP Healthy Michigan ID card, or if it is lost or stolen, pleasecall MHP Customer Service at (888) 327-0671. This is what your MHP Healthy Michigancard looks like:It is important that you carry both your ID cards. Showing your cards will help make sure billsfor your health care are mailed to MHP or to Medicaid and not sent to you.MHP Customer ServiceCustomer service can help you. You can call us during normal hours or after hours. Normalhours are Monday-Friday from 8:30 a.m. to 5:00 p.m. You can call us at (888) 327-0671 to askquestions. We can also help you get a new ID card or find a provider.2(888) 327-0671MclarenHealthPlan.org
Your PrivacyMHP cares about your privacy. We have a privacy notice available to all of our members. Wehave policies and procedures in place that protect the privacy of your information: Every MHP employee signs a statement when they are hired that states they are required tokeep member information private. Every MHP employee receives training every year on keeping information private. MHP only allows employees who are authorized with a password to access electronicinformation. Paper information is stored in secure locations. Only employees who need to see information to manage your health care have access to it.MHP’s Privacy Notice is located on page 21 of this Member Handbook and is also listed on ourwebsite at MclarenHealthPlan.org. If you have questions, please call Customer Service at(888) 327-0671.Your RightsYou have rights as an MHP member. You also have duties as an MHP member. MHP employeesand providers are aware of these rights and duties and agree to follow them. If you do notunderstand your rights and duties, please call Customer Service at (888) 327-0671.Your Rights The right to confidentiality. The right to be treated with respect and dignity and the right to privacy including to be freefrom restraint and seclusion. The right to have a primary care provider at all times. The right to a current listing of network providers and access to a choice of specialists withinthe network who can treat chronic problems. The right to get routine OB/GYN and pediatric services without a referral if the OB/GYN orpediatric specialist is a participating provider. The right to receive Federally Qualified Health Clinic (FQHC) services. The right to continue receiving medically necessary services from a provider who is no longer inthe MHP network. The right for female members who are pregnant to continue coverage with a provider who is nolonger in the MHP network (that includes up to 6 weeks after you have your baby). The right to have no “gag rules” from MHP (doctors are free to discuss all medicaltreatment even if they are not covered services). The right to participate in decision making regarding your health care.(888) 327-0671MclarenHealthPlan.org3
The right to refuse treatment, to get a second opinion, and to receive a copy of your medicalrecord upon request. The right to know how MHP pays its doctors. The right to be provided with a telephone number and address to obtain additional informationabout payment methods, if desired. The right to tell us if you have a complaint about MHP, the care provided, and the right toappeal a decision to deny or limit coverage. The right to know that you or your doctor cannot be penalized for filing a complaint or appealabout your care. The right to receive information about the structure and operation of MHP, including theservices, providers of care and your rights and duties. The right to make suggestions regarding MHP members’ rights and duties. The right to have your medical record kept confidential by MHP and your provider. The right to be free from other discrimination prohibited by state and federal regulations.Your Duties You should schedule appointments in advance and be on time. If you need to cancel an appointment with any doctor’s office, call as soon as possible. You should use the hospital emergency room only for emergency care (if possible, you shouldcall your doctor before going to the emergency room). You need to give all the information that you can to your doctors and MHP so they can carefor you in the best way. You need to ask questions if you do not understand the care you are getting. You need to talk about your care and help your doctors plan what you will be receiving. You need to complete the treatments that you have agreed to and follow all plans of care. You should tell the Department of Human Services (DHS) and Customer Service right awaywith any change in address or telephone number. You should help MHP assist you with your health care by telling us any problems youhave with services. You should tell us your suggestions in writing or by contacting Customer Service for assistance. You must carry your MHP member ID card at all times.Patient Advocate and Advance DirectiveMany people are worried about what to do if they become very sick or hurt and cannot tell otherswhat kind of care they would like. Some people do not want life support if they are in a comaand will be on machines for the rest of their life. Other people want to make sure that all possiblemedical care is given to them, even if they are in a coma for the rest of their life. In addition topicking a person to be an advocate for you in these situations, more people are writing downwhat they want other people to do for them.4(888) 327-0671MclarenHealthPlan.org
This is often called an advance directive. Now is a good time to write down youradvance directives because you can make your wishes known while you are healthy.Your doctor’s office has an advance directive form for you to fill out to tell your doctorwhat you want done. Your advance directive often includes a do-not-resuscitate order.Some people do this after talking to their doctor about their health status. It giveswritten notice to health care workers who may be treating you should you stopbreathing or your heart stops. Your doctor can help you with this if you are interested.If notice of your do-not-resuscitate order is given and is not followed, the treating person ororganization can be subject to civil or criminal liability. Please follow the complaint processon page 15 if this happens. If you have any questions about MHP policies, call CustomerService at (888) 327-0671 and they will help you understand this process.No one can force you to fill out the advance directive form. If you do fill out the form, you canchange it at any time. MHP wants to make sure you know your rights under the law. This isnot legal advice.For complaints about how your provider follows your wishes, write or call:Bureau of Health Professions (BHP), Complaint & Allegation DivisionP.O. Box 30670Lansing, MI 48909-8170(517) 241-2389bhpinfo@michigan.govThe BHP Complaint & Allegation website is www.michigan.gov/healthlicense (click on “filea complaint”).For complaints about how your health plan follows your wishes, call:Michigan Department of Insurance and Financial Services(877) 999-6442www.michigan.gov/difsHow to Get the Medical Care You NeedYour Primary Care Provider (PCP)When you join MHP, you pick a doctor from our list of doctors. You can choose from the listof family practice doctors, pediatricians or internal medicine doctors. This will be your PrimaryCare Physician (PCP). The name of your PCP will be on your ID card. It is your responsibilityto see your PCP within 60 days of becoming a MHP member. At your first appointment youand your PCP will complete Health Risk Assessment (HRA). An HRA is a tool used to helpyou get healthy and stay healthy. It is a good idea to meet with your PCP so you can talk aboutyour past medical history. This way, if you do get sick, your PCP will already know importantinformation about you. Both your PCP and MHP are available by phone 24 hours a day forquestions about care. MHP’s toll free number is (888) 327-0671.(888) 327-0671MclarenHealthPlan.org5
Be sure to contact your PCP to find out his/her after hours number. If emergency care isneeded, call 911 (see Page 11 for more information).Health Risk Assessment (HRA)This is a survey about your health. An HRA is a tool to help your PCP work with you tomeet your health needs in the best way possible. The HRA is confidential and subject toyour privacy rights. There are 3 sections on the HRA. Section 1 has 9 questions about yourhealth and lifestyle. Section 2 includes questions about making changes. Section 3 is foryour PCP to complete at your first appointment. All MHP members must complete anHRA.Making an AppointmentCall your PCP’s office to make an appointment or to see if you can walk in. Call as far aheadof time as you can. Tell your PCP’s office you are an MHP member. Tell them why you need tocome in and have a paper and pencil ready so you can write down the date and time. Be on timefor the visit.If you need to change the appointment, call your PCP’s office as soon as possible (at leastone day’s notice) and be sure to write down the new date and time. If you need help withtransportation to medical appointments, call Customer Service at (888) 327-0671.How to See a SpecialistYour PCP should decide if you need to see a specialist. If the specialist does not participate withMHP, a written referral is needed. Your PCP will fill out a form called a “referral”. Your PCP isthe only one who can ask for a referral to a specialist who does not participate with MHP.Changing Your PCPYour PCP is a big part of your good health. We hope you will choose your PCP carefully. Ifyou are unhappy with your PCP, please let them know what concerns you have.If you decide to change PCPs, you will need to: Pick another PCP from the McLaren Health Plan “Medicaid” list of providers. Call Customer Service at (888) 327-0671 to let them know the PCP you have selected.If you need help in finding a new PCP, Customer Service can help you.Having a Specialist as a PCPPatients with a chronic disease often need to see a specialist to obtain care. In limited cases, itmay be better for the specialist to be your PCP. You should call Customer Service at(888) 327-0671 if you think you need a specialist as your PCP. The specialist must agree tobe your PCP.6(888) 327-0671MclarenHealthPlan.org
For Your InformationMany doctors and other providers of health care will be taking care of you. The McLaren HealthPlan Medicaid Provider Directory lists health care providers’ names, addresses, telephonenumbers, specialties, and board certifications. If you want to know more about a provider’squalifications, such as medical schools attended or residency information, or if you want aprinted copy of anything on our website, call Customer Service at (888) 327-0671.Do I Need a Referral?MHP cares about you and your health. You have picked a PCP to handle your health care. MHPhas a referral process that helps your PCP know what is going on with you. Most of the time, youneed a written referral before you have services, but in some cases you don’t. Your PCP knowswhen a referral is needed and when it isn’t. You do not need a written referral from your PCP tovisit or receive most services in the office of an In-Network Specialist*. It is still recommendedthat you work with your PCP. If you think you need a second opinion you can get one from anin-network provider. If you want a second opinion from an out-of-network provider, callCustomer Service for assistance. Your PCP can help you get the most effective, high qualitycare. If you have a question about a certain health care service that may need a referral, callCustomer Service at (888) 327-0671. Any health care that you receive must be medicallynecessary. MHP pays for many covered services. Your PCP is the best person to decide whichhealth care services are medically necessary.The next two pages give short lists of: What Medicaid covers What the MHP Healthy Michigan Plan covers What is not covered at allSome of the services listed might need more explaining, so we have included additionalinformation to help you understand the service. Remember, you must use your Medicaidcard for services covered by Medicaid.*These In-Network services still require a referral: Injectable medications given in the office of an In-Network specialistSpecial NeedsIf you have special needs, call Customer Service and ask to speak to “your nurse.”Every MHP Healthy Michigan member has a nurse assigned to them. Special needs can besomething that makes you require some extra help and your nurse is there to help you with thosespecial needs. If you need help understanding the written materials or need interpretationservices, call Customer Service at (888) 327-0671. Please note, if a provider speaks a languagebesides English, it is listed by their name in the Provider Directory.If you are deaf, hard of hearing or have speech problems and you can access a TTY line, thenumber is (800) 356-3232. If you cannot access a TTY line, call 711 and Michigan Relaywill assist you. Both lines are available 24 hours a day.(888) 327-0671MclarenHealthPlan.org7
Member materials are available in other languages and formats, if needed. Please call CustomerService at (888) 327-0671 to request copies.Healthy BehaviorsWhen you complete your HRA with your PCP, your PCP will talk with you about your healthneeds. Your PCP will also ask you if you are ready to make any changes to improve your health.You may be able to get an incentive, just for taking care of yourself! If you are already healthy,you may be able to get an incentive just by staying healthy! Call Customer Service at(888) 327-0671 for details.Co-Payments or Co-Pays for ServicesThe MHP Healthy Michigan Plan has co-pays. When you are enrolled in a health plan, your copays will be payable to MHP through a special health care account called the MI Health Account.Co-pays will not be collected for the first 6 months after enrollment in a health plan but will bepaid to your health plan through your MI Health Account at a later time. Below is a table thatshows how much you could pay for health care services.The Healthy Michigan Plan requires those with annual incomes between 100% and 133% of thefederal poverty level to contribute 2% of income annually for cost sharing purposes. You will getmore information about your MI Health Account and contributions for cost sharing from MHP.You can reduce your annual contribution and co-pays by participating with your health plan inhealthy behavior activities. Cost sharing cannot exceed 5% of your income.MHP Healthy Michigan Co-PaysCovered ServicesPhysician Office Visits (including Free-Standing Urgent Care Centers)Outpatient Hospital Clinic VisitEmergency Room Visit for Non-Emergency Services Co-payment ONLY applies to non-emergency services There is no co-payment for true emergency servicesInpatient Hospital Stay (with the exception of emergency admissions)PharmacyChiropractic VisitsDental VisitsHearing AidsPodiatric VisitsVision Visits8(888) 327-0671MclarenHealthPlan.orgCo-Pay 2 1 3 50 1 generic 3 brand 1 3 3/aid 2 2
Not all services have co-pays and not all people are required to pay copays. For example, servicesthat help you get or stay healthy, like preventative services or certain services or medications thathelp you manage a chronic condition, may have no copays. Also, some people don’t have to paycopays at all, like those who are under 21.The amount you owe could be different than what is shown in the table on page 8. Theseamounts are for informational purposes only. Your MI Health Account Statement will tell youwhat you have to pay and how the amounts were figured.Services Covered by Medicaid (not your MHP Healthy Michigan Plan)Here is a list of medical services that MHP will not pay for, but they are still covered because youqualify for Medicaid. Use your plastic Medicaid ID card for these services. If you have anyquestions, talk to your caseworker about these services. Care for Developmental Disabilities(provided through CommunityMental Health) Custodial Care in a Nursing Home Inpatient Psychiatric Care Home and Community BasedWaiver Program Care Intermittent or Short-term Restorative orRehabilitative services (in a nursingfacility), after 45 days Maternal Infant Health ProgramServices Mental Health Care, over 20 OutpatientVisits each Calendar Year Outpatient Partial Hospital PsychiatricCare Personal Care or Home Help Rides for Care Not Covered by McLarenHealth Plan Healthy Michigan butcovered by Medicaid Substance Abuse Treatment* Mental Health Services According toGuidelines under Policy for SeriousMental Illness/Severe EmotionalDisturbance*Drug and Alcohol Abuse Care: If you think you or a covered family member may need thistype of care, speak with your PCP. Some warning signs can be drinking alcohol every day, usingillegal drugs or being unable to stop either one by yourself.Medicaid covers substance abuse care, including: Screening and Exam Detoxification Intensive Outpatient Counseling and Other Outpatient Services Methadone Residential ServicesCall Customer Service at (888) 327-0671 and they can give you a number to call for help.(888) 327-0671MclarenHealthPlan.org9
Services NOT Covered by your MHP Healthy Michigan Plan or Medicaid: Abortions or Cosmetic Surgery by Choice Try Out Drugs, Tests or Equipment Unneeded Care Care That Needed a Referral but Didn’t Have a Referral Treatment for InfertilityServices Covered by your MHP Healthy Michigan PlanYour MHP Healthy Michigan Plan covers the federal healthcare law “essential health benefits,” aswell as other services and benefits. Ambulance when Necessary Certified Nurse Midwife Chiropractic Services (up to 18 visitsper calendar year, additional visitsrequire prior authorization) Dental Services Diagnostic Services (lab, X-ray,other imaging) Durable Medical Equipment and Supplies Emergency Services, includingTransportation End Stage Renal Disease Services Family Planning Habilitative Services Health Education Hearing and Speech Hearing Aids Home Health Services Hospice Services Immunizations (shots) Inpatient Hospital Services Medically Necessary Weight Reduction Mental Health Care (up to 20outpatient visits per calendar year) Office Visits to Your Doctor Orthotic Services Out of State Services, when Authorized Outpatient Hospital Services Parenting and Birthing Classes Pharmacy Services Podiatry Prosthetic Services Sexually Transmitted Infection (STI)Treatment Intermittent or Short-term Restorative orRehabilitative Services (in a NursingFacility), up to 45 days; Restorative orRehabilitative Services (in a place otherthan a nursing facility) Specialist Visits with Referrals Therapy (speech, language, physical andoccupational) Services Tobacco Cessation Treatment Transplant Services Transportation Vision ServicesYou can call Customer Service at (888) 327-0671 if you have any questions about the aboveservices. If you do not understand the limits or if you are told something is not covered, pleasecall Customer Service for more information.Most Often Asked Questions about Covered ServicesCustomer Service can help you with most of your questions. The Customer Servicerepresentatives know all about MHP. They can help you connect with your PCP. They canconnect you with your McLaren Health Plan nurse if you have questions about your medicalcare. Customer Service can be reached at (888) 327-0671.10(888) 327-0671MclarenHealthPlan.org
We have listed some questions that many people call about. Please see the list below to helpyou understand your health care services. Remember, if you are told a service is not a coveredbenefit, call Customer Service to verify.Doctor Services: What’s covered? Office Visits Routine Physicals Routine Immunizations (shots) Podiatry (foot) careIf your doctor has a question regarding your benefits, have him/her call Customer Service at(888) 327-0671.Durable Medical Equipment and SuppliesWhen needed, your MHP Healthy Michigan Plan covers durable medical equipment(equipment that can be used for a long time) and medical supplies (supplies that cannot bere-used). Your doctor will give you a referral for these services.Emergency and Urgent CareEmergency care is when something bad happens that causes you to need medical care rightaway. When you have an emergency or if your health would be in danger if you do not see adoctor at once, call 911 or go to the nearest hospital.Some examples of emergencies are: Bad Burns or a Bad Cut Bad Car Accident Bleeding That Won’t Stop Broken Bones Choking Gunshot Wound Heart Attack Poisoning Trouble BreathingEmergency rooms are for serious medical conditions only. Treatments at urgent care centers arealso covered. You can call your PCP if you are unsure whether something is an emergency.Rural Health Clinics(RHCs) and Tribal Health CentersRHC or Tribal Health Center services are covered for members without a referral. McLarenHealth Plan will pay for the covered services you get from these programs. You will need to letthe center know that you have the MHP Healthy Michigan Plan.Dental ServicesIf you are enrolled in a health plan, you will get your dental check-ups through your healthplan dentist. If you are NOT enrolled in a health plan, you will get your dental check-ups fromdentists in your area who work with the Healthy Michigan Plan.(888) 327-0671MclarenHealthPlan.org11
Those 19 and 20 year olds NOT in a health plan, and who live in one of the Healthy KidsDental counties, may have dental services through Healthy Kids Dental- Delta Dental. Youcan check to see if you live in one of the Healthy Kids Dental counties on the Delta Dentalweb page at www.deltadentalmi.com/hkd.Eye Care Includes: One Eye Exam Every 24 Months One Pair of Glasses Every 24 Months A Large Choice of FramesYou can go to a MHP eye care center without a referral from your PCP. If you are a diabetic,you can go to an In-Network eye professional every year without a referral.You can find a list of MHP In-Network eye care centers in the McLaren Health Plan MedicaidProvider Directory at MclarenHealthPlan.org, or you can call Customer Service at(888) 327-0671.Family Planning ServicesFamily Planning means helping you not get pregnant until you want to get pregnant. Youdo not need a referral for Family Planning. You can get Family Planning at your doctor’soffice, at the health department or another family planning place. You can get advice,exams, and supplies. Family Planning does not include abortions.Federally Qualified Health Clinic (FQHC) ServicesFQHC services are contracted and available to all MHP Healthy Michigan members.The specific listing of FQHC services is found in the McLaren Health Plan MedicaidProvider Directory.Health EducationMHP has a lot of books and classes to help you stay healthy. We can help you learn moreabout Family Planning, how to stop smoking, new parenting, breast feeding, CPR, weightloss, first a
The Medicaid card is plastic and has “mihealth” written on it. You will get a regular plastic Medicaid card from the State to use for services you still get through Medicaid. Call Medicaid at (800) 642-3195 if you did not get a plastic Medicaid card or if yo
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We started racing over 50 years ago and have pushed the boundaries . of better ever since. This thinking is what makes a McLaren a McLaren. . So nothing draws your attention away from the experience – and fun – of driving. Of course, you’ll probably want to make the environment your
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