MIChild Member Handbook

Transcription

1 MIChild Member Handbook

2 WELCOME...3 MEMBER RIGHTS & RESPONSIBILITIES...4 Membership Rights...4 Membership Responsibilities...5 YOUR PHP FAMILYCARE MICHILD I.D. CARD...6 Member identification card...6 YOUR PRIMARY CARE PROVIDER AND YOU...6 Choosing your PCP...6 Can I have a specialist as a PCP?...7 How do I change my PCP?...7 When do I call my PCP?...7 How do I make a doctor s appointment?...8 What if I need to change or cancel an appointment?...8 What if I need to see a specialist?...8 When can I see an OB/GYN or pediatrician?...8 Can I go to a Federally Qualified Health Center?...8 Can I continue to see my doctor if they have terminated from PHP FamilyCare MIChild?...9 What do I do if I have an emergency and I am out of town?...9 Can I go to a non-network provider?...9 How do PHP FamilyCare MIChild providers get paid?...10 Does my doctor receive any incentives?...10 EMERGENCY AND URGENT CARE...10 What is an emergency?...10 What should I do in an emergency?...10 When should I call 911?...11 How can I reach PHP FamilyCare MIChild after hours?...11 What is urgent care?...11 SERVICES COVERED BY PHP FAMILYCARE MICHILD...11 Eye exams and glasses...12 Durable medical equipment...12 Hospice services...12 Mental health...12 Substance use disorder services...13 Pharmacy benefits...13 Pregnancy services...14 Early, periodic screening diagnosis and treatment (EPSDT)...14 Pediatric care...14 Family planning services

3 Child and Adolescent Health Center...14 Sexually transmitted disease (STD) services...15 Centers for Disease Control and Prevention National Immunization Program...15 Care Management Program...15 Children s Special Health Care Services (CSHCS) Program...15 Additional benefits for MIChild enrollees with Children s Special Health Care Services...16 MEDICAL RESOURCE MANAGEMENT (MRM)...16 Some services that require notification and/or authorization are:...17 Making decisions on your coverage...17 SERVICES NOT COVERED BY PHP FAMILYCARE MICHILD...18 CUSTOMER SERVICE...19 How can the PHP FamilyCare MIChild Customer Service Department help me?...19 If I move, who should I call?...19 What if I get a bill?...19 Do I get a member identification card?...20 What if I have a change in my Insurance coverage?...20 What if there is a change in my family situation?...20 If you lose MIChild eligibility...20 Is there any other way I could lose my PHP FamilyCare MIChild eligibility?...20 Important Phone Numbers...21 COMMUNICATION SERVICES...21 TTY/TDD Services...21 AT&T Language Line Service...21 Interpretation Services...21 CONFIDENTIALITY...21 Routine Consent...21 Special Consent...22 How to contact us if there is a problem...22 APPEAL PROCESS...22 Step Step External Review by the Michigan Department of Insurance and Financial Services (DIFS)...24 Exceptions for Urgent Situations...24 OTHER INFORMATION...24 New Technology...24 Advance Directives...25 Patient Bill of Rights...25 Who to call...26 HELP US STOP MEMBER FRAUD AND ABUSE...26 What is fraud and abuse?

4 WELCOME Welcome to PHP FamilyCare MIChild program. PHP FamilyCare MIChild provides health care coverage that helps you manage your health care needs. When you join PHP FamilyCare MIChild, you must choose a primary care provider (PCP). This primary care provider is a doctor that will be your partner in health care choices. Please read the Member Handbook and Certificate of Coverage (COC) inside your member packet. Both books will help you to understand and use your PHP FamilyCare MIChild benefits. Please keep it in a safe place for future use. PHP FamilyCare MIChild has a Customer Service Department and staff to help you or get you information when you need it. They will help you if you want to change your doctor or need to change your address. They will help you to understand how PHP FamilyCare MIChild works. They will also assist you, listen to your problems or complaints, and get back to you with an answer. You can have someone you know help you understand this information. If you want to designate someone to help you, let us know. PHP FamilyCare MIChild will work with other family members or caregivers. Call our Customer Service Department at or :30 am -5:30 pm, Monday-Friday Visit our web site at Select PHP FamilyCare/MIChild Visit us in person at our office PHP FamilyCare MIChild 1400 E Michigan Ave Lansing, MI

5 MEMBER RIGHTS & RESPONSIBILITIES Membership Rights PHP FamilyCare MIChild staff and contracted providers will comply with all requirements concerning member rights. Enrollment with PHP FamilyCare MIChild entitles you to: 1. Be given information about your rights and responsibilities as a member. 2. Be treated at all times with respect, consideration, dignity and privacy. 3. Get information about all covered health services consistent with the contract with the State of Michigan, State and Federal regulations, including clear details of how to locate and use them. 4. Services as covered under the plan, provided that these services are from participating providers except as otherwise indicated in this handbook. 5. Know that your medical records and letters are treated in a private manner. They will only be given as required by law or permitted by you. 6. You have the right to review your medical record with your provider. You have the right to request and review your medical records obtained by PHP FamilyCare MIChild. You have the right to correct or amend your medical records. 7. Choice of a PCP from a list of participating providers. 8. Full information on the nature and effect of any treatment, test or procedure that may be involved in your health care, regardless of cost or benefit coverage. 9. Take part in decisions involving your health care. 10. Make decisions to accept or refuse medical or surgical treatment. 11. Be given information on the effects of refusing or not following the treatment. 12. Refuse to participate in new research. 13. The use of the plan s problem resolution process, including the ability to voice complaints, grievances or appeals about PHP or the care provided without fear of being penalized and/or without fear of loss of coverage. 14. Be free from any form of restraint or reclusion used as a means of coercion, discipline, convenience or retaliation. 15. Choices on Advance Directives. Advance Directives are instructions you write for your providers to let them know how you want to be treated if you are too sick to tell them. You write this before you are too sick to make the choice. 16. Be free from other discrimination prohibited by State and Federal regulations. 17. Make suggestions regarding PHP FamilyCare MIChild s member rights and responsibilities policies. 4 phpmm.org

6 Membership Responsibilities 1. You must select a primary care provider (PCP) from PHP FamilyCare MIChild s list of providers. 2. All medical care, except in emergencies, or as otherwise stated in the Member handbook, must be from a plan provider. All visits to non-participating providers must be approved first by PHP FamilyCare MIChild. 3. All hospitalizations must be approved. Your doctor will make the plans and contact PHP FamilyCare MIChild. This does not apply to emergencies or for urgently needed health services. 4. Emergency Room (ER) services may be used only for treatment of serious medical conditions. These would result from injury, sickness or mental illness, which arises suddenly and requires immediate care and treatment. ER treatment is needed generally within 24 hours of the problem. 5. You must make visits with your PCP as far in advance as possible. Call if you are unable to keep an appointment. 6. You must always carry your PHP FamilyCare MIChild ID card. Never let someone else use your cards. 7. Report any lost or stolen health cards. Call PHP FamilyCare MIChild Customer Service if your health plan ID card is missing. 8. Call our Customer Service Department if you have a question about your plan coverage. 9. You must notify the plan of any changes in your address, or if you have other health insurance coverage. 10. You must provide complete information about your health and health care to the health plan and your doctor in order for them to care for you. 11. Work with your PCP to manage your health problems and treatment goals. 12. You must follow the steps for care that you agree on with your PCP

7 YOUR PHP FAMILYCARE MICHILD I.D. CARD Member identification card Your PHP FamilyCare MIChild ID card is very important. Every person who is covered by PHP FamilyCare MIChild has his or her own ID card. Your name and member number are on the front of your ID card. Important phone numbers are found on the back. Please call PHP FamilyCare MIChild s Customer Service Department if your PHP FamilyCare MIChild ID card has: k Been lost or stolen k An error on it Carry your PHP FamilyCare MIChild ID card with you at all times. Letting someone else use your ID card can result in the loss of your health care coverage with PHP FamilyCare MIChild. YOUR PRIMARY CARE PROVIDER AND YOU Choosing your PCP When you join PHP FamilyCare MIChild, you must pick a PCP. Your PCP is your main doctor. Your PCP will see you for all your routine health care needs. Your PCP is in charge of managing your care by referring you to specialists, other healthcare providers, and hospitals. How do I choose a PCP? The PHP FamilyCare MIChild Provider Directory is available by calling Customer Service at The Provider Directory will be mailed within 5 days of your call. You can also look at the Provider Directory on the PHP website: Click on the Provider Directory to find a doctor. Customer Service will help you find a doctor as well. Each family member may have a different doctor. Below are the types of doctors you can pick as your PCP: k Family/General Practice - doctors who see patients of all ages for general health care. k Internal Medicine - doctors who treat only adults. They do not do surgery or deliver babies. k OB/GYN - doctors who care for women and deliver babies. k Pediatricians - doctors who see only children to age 16, sometimes phpmm.org

8 Can I have a specialist as a PCP? People with a chronic health condition may need to be seen by a specialist on a regular basis to get needed care. In some cases, it may be better for the specialist to be responsible for all of your health care needs. If you think you need a specialist as your PCP, please call the Customer Service Department. How do I change my PCP? Your PCP is important to your health care. We hope that you will pick yours carefully and be happy with your choice. Sometimes there may be a reason why you need to change your PCP. Here are some reasons: k You have moved and now your doctor is too far away. k You are unhappy with your doctor. k Your doctor is no longer a part of PHP FamilyCare MIChild. When you feel that you need to change to another PCP, you will need to: k Pick a new PCP from PHP FamilyCare MIChild s Provider Directory. Check our website: or call the Customer Service Department. They will help you find a doctor or mail you a provider directory. k Call PHP FamilyCare MIChild s Customer Service Department to let them know that you have picked a new PCP. k Call PHP FamilyCare MIChild s Customer Service Department if you need help in finding a new PCP. When you change your PCP, it will be effective immediately. Please make a get to know you visit with your new PCP. When do I call my PCP? You should call your PCP for the following reasons: k When you need routine care k When you need lab work, tests, etc. k As needed to see a specialist k When a sudden illness or injury happens (anytime, day or night) k To be admitted to a hospital In a life-threatening emergency, call

9 How do I make a doctor s appointment? Call your PCP s office in advance during regular business hours and set up an appointment. When you call the doctor s office, tell them that you are a PHP FamilyCare MIChild member. Also, tell them why you need to see the doctor. If you are sick or hurt, call your doctor early in the morning, as you may be able to see the doctor on that day. It is important to be on time! Always be prepared for your doctor s appointment. Have your questions ready for your doctor. Be sure to tell the doctor about your symptoms and medications you are taking. If you have a question and the office is closed, an answering service will refer your call to your PCP or the doctor on call. What if I need to change or cancel an appointment? If you cannot keep an appointment, always call your doctor s office as soon as possible. The doctor s office will help you pick a new time. Some offices have a policy that if you miss one or more appointments, you will not be allowed to see that doctor anymore. What if I need to see a specialist? Sometimes your PCP may feel that you need to see another doctor or specialist. Your PCP will give you a referral to get care from another doctor or specialist. You cannot go to another doctor or specialist without the referral from your PCP, except as otherwise stated in this handbook. If you receive medical services without getting a referral from your PCP, you may have to pay for the services. Your PCP will also give you a referral for other services you receive. Those services could be outpatient hospital care, hospice care, or medical supplies like wheelchairs and crutches. If you receive any of these services without a referral from your PCP, you may have to pay for them. When can I see an OB/GYN or pediatrician? You do not need a referral from your PCP if you want to see an OB/GYN doctor for a well woman visit or routine OB care. You may go to any OB/GYN doctor in the PHP FamilyCare MIChild Provider Network. Please call our Customer Service Department or visit our website if you need help in finding an OB/GYN doctor. If your child does not have a pediatrician for their PCP, you may still get routine services without a referral from a PHP FamilyCare MIChild pediatrician. If you go to a doctor that is not in the PHP FamilyCare MIChild Provider Network, you will need a referral from your PCP. Please call the PHP FamilyCare MIChild Customer Service Department or visit our website if you need help to find a pediatrician. Can I go to a Federally Qualified Health Center? If there is a Federally Qualified Health Center (FQHC) in your county, you may choose to receive routine provider services from them. (Ingham County Health Department is a FQHC in Ingham 8 phpmm.org

10 County). You do not need a referral from your PCP for these services. However, the FQHC cannot refer you to other providers unless they are participating providers. You must call your PCP for this. Can I continue to see my doctor if they have terminated from PHP FamilyCare MIChild? If your PCP is no longer part of the PHP FamilyCare MIChild network, you will have to pick a new PCP. If you see a specialist who is no longer part of the PHP FamilyCare MIChild network, you may be able to keep seeing that doctor. The doctor must agree to keep seeing you. You must also have one of the following conditions: k k k You are in an ongoing course of treatment, or; You are in your 2 nd or 3 rd trimester of pregnancy, or; You are terminally ill. The amount of time that you can keep seeing that doctor depends on which condition applies to you. What do I do if I have an emergency and I am out of town? If you are out of state or not close to home and have an emergency, go to the closest hospital. The hospital can call PHP FamilyCare MIChild to make sure you are covered. If you are away from home and become ill, but not sick enough to go to the hospital, please call your PCP. You will be advised to go to an Urgent Care Center or a doctor s office. Routine care is not covered when you are out of the PHP FamilyCare MIChild Service Area. Your PCP should do all of your routine care. Anytime you are out of the PHP FamilyCare MIChild Service Area and you have any questions, contact us. Please call PHP FamilyCare MIChild s Medical Resource Management (MRM) Department at or toll free at Please read about What is an Emergency and Urgent Care on pages 9 &10. Can I go to a non-network provider? In some cases, your PCP may refer you to a provider who is not in the PHP FamilyCare MIChild network. Your PCP will need to contact PHP FamilyCare MIChild to have this approved. Except as otherwise stated in this handbook, PHP FamilyCare MIChild members will only be allowed to use non-network health care providers when all of the following apply: k k k The services cannot be provided by a participating provider. The services are medically necessary; and The services have been approved in writing, in advance, by PHP FamilyCare MIChild

11 How do PHP FamilyCare MIChild providers get paid? PHP FamilyCare MIChild providers are normally paid by Fee for Service : The Fee for Service method is a method of paying a set amount for each covered service. This amount is usually less than the amount the doctor would normally bill. In some cases, PHP FamilyCare MIChild providers may receive additional payments. These payments will vary based on standards related to cost, quality, and use of services or patient satisfaction. Does my doctor receive any incentives? You may ask if we have special financial arrangements with our doctors that can affect the use of referrals and other services that you might need. Please call our Customer Service Department if you have any questions. EMERGENCY AND URGENT CARE What is an emergency? Emergency care is care that is needed right away. Emergency care is usually received within 24 hours of onset to avoid disability or death. An emergency is defined as a condition that happens suddenly and is so severe that if not treated would cause: 1. Serious harm to your health 2. Serious impairment to your body functions 3. Serious damage to any body organ or part The symptoms below can signal an emergency: Choking Unconsciousness Convulsions Severe bleeding Broken bones Heart attacks/chest pain Strokes What should I do in an emergency? Severe breathing problem If you have an injury or sudden illness call your PCP. You should follow what your PCP tells you to do. If you don t have enough time to call your doctor, call 911. If your problem is life threatening, call 911 or go to the nearest emergency room. Your PCP must do all of your follow up care and 10 phpmm.org

12 you must let your PCP know what happened. Do not use the emergency room for an illness that can be treated at your PCP s office during regular business hours. When should I call 911? Some emergencies need to be treated by trained medical staff right on the spot. This is needed when the person is unconscious or cannot be easily moved. Call 911, tell them the problem, and give clear directions as to where you are. How can I reach PHP FamilyCare MIChild after hours? If you cannot reach your PCP, call PHP FamilyCare MIChild Customer Service. The after-hours answering service will take down your information and will assist you or call the On-Call nurse if necessary. The On-Call nurse will call you back. What is urgent care? Sometimes you need medical care quickly, but it is not an emergency. This is called urgent care. Call your PCP if you need urgent care during regular office hours or after doctor s office hours or on the weekends. Some examples of reasons that you would go to an Urgent Care Center are listed below: Severe stomach ache Sore throat with a high fever Sprains Prolonged vomiting or diarrhea Frequent urination with pain Allergic reaction SERVICES COVERED BY PHP FAMILYCARE MICHILD Coverage is available if the service is medically necessary. The services listed below, and the times when they are covered are described in more detail in your COC. Review your COC to get a better understanding of what services are covered. Covered services are: k Ambulance and other emergency medical transportation k Ambulatory (Outpatient) surgery k Artificial limbs and orthotics k Acupuncture Therapy for certain illnesses k Blood tests for children to check for lead k Certified Nurse Midwife services k Certified Pediatric and Family Nurse Practitioner services k Childhood preventative immunizations k Chiropractic services k Dental services (only for treatment related to an accident) k Early periodic screening, diagnosis and treatment services (EPSDT) k Emergency services k Family planning services k Health education and outreach k Hearing aids k Hearing services

13 k Home health care services k Hospice services k Inpatient hospital services k Intermittent or short-term restorative or rehabilitative services; up to 120 days in a nursing facility k Kidney failure, including dialysis services k Laboratory, x-ray, and other diagnostic services k Maternity care k Medical supplies and equipment k Medically necessary weight reduction services k Out of State services with approval k Outpatient hospital services k Parenting and birthing classes k Physical, Speech and other therapies k Physician and other practitioner services k Prescription drugs k Preventative care and screenings k Tobacco Cessation services, including drug and support services k Transplant services k Treatment for sexually transmitted diseases (STD) k Vision services k Well Child/EPSDT services Eye exams and glasses PHP FamilyCare MIChild covers vision services when provided by a PHP FamilyCare MIChild network provider. PHP FamilyCare MIChild will cover eye exams and certain types of prescription eyeglasses. k Annual vision exam. k One pair of glasses is covered once every 24 months or once every 12 months with a prescription change. k Services needed as a result of eye trauma and eye disease. You do not need a referral from your PCP for a routine eye exam. Eye exams for a medical problem will be covered. Durable medical equipment PHP FamilyCare MIChild covers necessary durable medical equipment such as crutches or wheelchairs. In most cases, you must get your durable medical equipment from a provider in the PHP FamilyCare MIChild network. Hospice services Hospice service is a medical program designed to provide for and relieve the suffering of terminally ill people. PHP FamilyCare MIChild covers hospice services. Mental health Your local Community Mental Health (CMH) Agency will help you if you need mental health services. If medicines are prescribed by a provider in the CMH the State MIChild program will cover these medications. 12 phpmm.org

14 Medications for attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) are covered if written by your PCP or specialist. You can find information about local Community Mental Health Agencies in your county in the phone book. PHP FamilyCare MIChild Customer Service can also assist you. Substance use disorder services You may have a problem with drugs or alcohol. Some signs that you may have a problem are: k You feel like you have to have drugs or alcohol to make you feel good. k Alcohol or drugs cause problems in your life. k You can t remember what happened while you were drinking or on drugs. k People you live with or work with complain about your drinking or taking drugs. k You feel sick when you stop drinking or stop taking drugs. k You feel guilt, anxiety, depression, fear, or violent because of drinking or taking drugs. Services for substance use disorders are covered by the State MIChild program, not by PHP Family- Care MIChild. Listed below are some referral sources: k Central Diagnostic and Referral Services is responsible for referral and utilization management services for Clinton, Eaton, and Ingham Counties. Contact them at k Mid-South Substance Abuse Center is responsible for referral and utilization services for Ionia County. Contact them at k Access Alliance of Michigan is responsible for referral and utilization services for Shiawassee County. Contact them at Medications prescribed for the purpose of substance use disorders and methadone treatment are not covered by PHP FamilyCare MIChild. Discuss this with your substance use disorder provider. Pharmacy benefits PHP FamilyCare MIChild provides coverage for prescription drugs. Your doctor will decide if and when you need a drug. You will need a prescription to get the drug you need. You will need to show your PHP FamilyCare MIChild ID card when you go to the pharmacy. There are many local pharmacies in the PHP FamilyCare MIChild network. Please look in your PHP FamilyCare MIChild Provider Directory for the pharmacy nearest you. PHP FamilyCare MIChild has a list of covered and non-covered drugs. There are some drugs that your doctor must call PHP FamilyCare MIChild to get approved before you can get them. PHP FamilyCare MIChild will also cover certain over-thecounter (OTC) medications as long as you have a prescription from your doctor

15 Medications for attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) are covered if written by your PCP or specialist. Please call the PHP FamilyCare MIChild Customer Service Department at if you have any questions about your prescription drug coverage. Pregnancy services The first step to having a healthy baby is to learn all you can about your health. Proper care during pregnancy is the best way to be sure you have a healthy baby. If you think you may be pregnant, call your doctor right away. Your baby s health and your health depend on it. Discuss your health background and lifestyle with your doctor. This will help your doctor see if you are at risk of early labor. Early, periodic screening diagnosis and treatment (EPSDT) There is a special program for children covered by MIChild. It is called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). This program provides regular health checkups for your child. These well child checkups are important! EPSDT can help with: k Finding your child s health problems early. If you think your child has a medical problem, talk with your doctor about EPSDT. k Providing information about all the special health services available for your children. k Keeping your children healthy by giving them the shots they need, when they need them. Pediatric care Care for children may be received from a pediatrician or any other PCP or certified nurse practitioner. Children may be seen by a PHP FamilyCare MIChild network pediatrician for routine/general services without prior authorization or referral. Family planning services You can get family planning services from your PHP FamilyCare MIChild doctor. You can also get family planning services from other providers. This may include another doctor, a nurse practitioner, a family planning clinic, adolescent health center or your local health department. You do not need a referral from your PCP to see another PHP FamilyCare MIChild doctor or nurse for family planning services. Child and Adolescent Health Center You can also choose to obtain services covered by PHP Family- Care MIChild from a Child and Adolescent Health Center and Program (CAHCP). If you choose to obtain services at a local CAHCP you do not need a referral to see the provider there. If there is a service that does require a referral you and the provider should follow the rules listed in this Member Handbook. 14 phpmm.org

16 Sexually transmitted disease (STD) services STDs are spread through sexual contact. If you think that you have an STD, there is help for you. Your doctor can offer you testing, treatment and counseling. All information about your care will be confidential. You can get care from your PCP, your local health department or a family planning clinic listed in your PHP FamilyCare MIChild Provider Directory. You do not need a referral from your PCP for these services. Centers for Disease Control and Prevention National Immunization Program The Centers for Disease Control and Prevention (CDC) offers a toll free service for people to request information on both childhood and adult immunization shots. Information available includes: k When shots should be taken and how to keep track of them k Possible side effects k Why shots are important to your health k Answers to frequently asked questions The number to call is: (English) (Spanish) Phones are answered from 8:00 a.m. to 11:00 p.m. EST Monday through Friday. At other times, you can leave a recorded message and get a response in 2-3 business days. Care Management Program We want to make sure that you receive quality health care. We will work with your providers to: k Make sure we know about all your hospital stays and the services you may receive. k Make sure you receive any services you need after you leave the hospital. k Make sure you receive care management services if needed. If you have any questions, please call Children s Special Health Care Services (CSHCS) Program CSHCS is a state of Michigan program that serves children, and some adults, with special health care needs. CSHCS covers more than 2,700 medical diagnoses. Additional benefits for MIChild enrollees with Children s Special Health Care Services k Help from your Local Health Department with:

17 k Community resources schools, community mental health, financial support, childcare, Early On, and the Women Infants and Children (WIC) program k Transitioning to adulthood k Orthodontia Only for specific CSHCS qualifying diagnosis, such as Cleft Palate/Cleft lip Medically necessary, related to condition Not for cosmetic purposes k Respite Care CSHCS covers 180 hours of respite care annually when a beneficiary requires skilled nursing and a CSHCS nurse consultant determines appropriate 2. Help from the Family Center for Children and Youth with Special Health Care Needs k CSHCS Family Phone Line a toll-free phone number ( ) available Monday through Friday from 8 a.m. to 5 p.m. k Parent-to-parent support network k Parent/Professional training programs k Financial help to go to conferences about CSHVS medical conditions and Relatively Speaking, a conference for siblings of children with special needs. k Help from the Children s Special Needs (CSN) Fund The CSH Fund helps CSHCS families get items not covered by MIChild or CSHCS. To see if you qualify for help from the CSN Fund, call Examples include: k Wheelchair ramps k Van lifts and tie downs Therapeutic tricycles Air Conditioners Adaptive recreational equipment Electrical service upgrades for eligible equipment MEDICAL RESOURCE MANAGEMENT (MRM) MRM is a department of health care providers: doctors, nurses and others with health care experience. Together they rely on processes to assure access to health care resources. They monitor the delivery of health care services through benefit reviews called authorizations and/or notification. PHP FamilyCare 16 phpmm.org

18 MIChild uses MRM to help us make decisions about covered health services. Decisions about covered health services are based on the member s covered benefits, Certificate of Coverage, standard medical practices and medical correctness as determined by the treating or referring doctor. You can request a copy of the benefit determination guideline. Services are never denied because of cost alone. There are some services that your doctor must call PHP FamilyCare MIChild for in advance. We will talk with you to about our network doctors and providers to make sure you receive the quality of care and services you deserve. Some services that require notification and/or authorization are: k Inpatient facility admissions k Home health care service k Complex equipment and supply needs k Out of network services k Hospice k Pharmacy requests Making decisions on your coverage PHP FamilyCare MIChild does not reward any associates (such as MRM, Pharmacy staff or medical directors) for denying services. We also do not allow any kind of incentive program that would award associates for making denial decisions. k There is no bonus program for this activity. k PHP FamilyCare MIChild does not track denials or approvals to provide a bonus or incentive to any associate, including those who make coverage decisions. k PHP FamilyCare MIChild does not have reward programs with doctors or other providers of care that support under utilization of proper services. PHP FamilyCare MIChild does have programs in place to alert us of under utilization. If necessary health care services are not delivered, a member could have serious medical problems. Failing to deliver needed services may cause a need for more serious or expensive health services later on. PHP FamilyCare MIChild has several disease management programs available to members that target exact areas of under utilization. Some of our programs include: Healthy Mom Healthy Baby, Living with Diabetes, and AsthmaWatch. PHP FamilyCare MIChild staff are always striving to promote correct utilization and direct members to proper care when they need it. You may voluntarily enroll in one of

19 these programs by contacting Customer Service. PHP FamilyCare MIChild also has case management services, which finds members who may have gaps in care. We work with the doctor and member to eliminate the gaps and coordinate care and services. We also focus on educating members about after hospital care. Please call if you have questions about the review process, or questions about benefit decisions. The MRM department can be reached at: or Monday through Friday from 8:00 a.m. to 5:00 p.m. or after hours by calling or SERVICES NOT COVERED BY PHP FAMILYCARE MICHILD PHP FamilyCare MIChild does not pay for the services listed below. Review your COC to get a better understanding of what services are not covered by PHP FamilyCare MIChild. Please call Customer Service if you need help to find out about these services. We would be happy to get you to the right MIChild agency that can help you. k Dental services. k Mental health services, including prescriptions written by the Community Mental Health Service Program (CMHSP) k Substance use disorder/detoxification services through accredited providers including: Detoxification Intensive outpatient counseling and other outpatient services Medications prescribed specifically for the purpose of substance use disorders Methadone treatment Screening and assessment k Long-term basic care or custodial services. Transportation for care and/or services not covered by PHP FamilyCare MIChild. Services provided by a school district and billed through the Intermediate School District. Personal care or home help services. Some developmental disability care. Intermittent or short-term restorative or rehabilitative services Maternal Infant Health Program (MIHP) 18 phpmm.org

20 k The services listed below are excluded by PHP FamilyCare MIChild as well as the State MIChild program: Any services not medically necessary Elective abortions and related services unless a physician certifies that the abortion is medically necessary to save the life of the mother or in cases of rape or incest. Elective cosmetic surgery Experimental or investigational drugs, procedures or equipment Services for treatment of infertility FOR A FULL LIST OF SERVICES THAT ARE COVERED AND NOT COVERED, PLEASE READ YOUR CERTIFICATE OF COVERAGE. CUSTOMER SERVICE How can the PHP FamilyCare MIChild Customer Service Department help me? PHP FamilyCare MIChild has a Customer Service Department to help you: k Answer your questions k Change your PCP k Connect you with the help you need k Assist you with any problems or complaints you have about our services and get back to you with an answer k Help you fill out the Health Care Request for External Review form k Obtain this handbook in other formats for members with special needs If I move, who should I call? k Michigan Enrolls at k Our Customer Service Department at or It is important for us to be able to reach you with important information. We will be happy to help you find a new doctor closer to your house if necessary. What if I get a bill? PHP FamilyCare MIChild members should not get bills for covered health services received while you are a member. If a bill is sent to you, call our Customer Service department

21 Do I get a member identification card? Your PHP FamilyCare MIChild ID card is very important. Every person who is covered by PHP FamilyCare MIChild has his or her own ID card. Your name and member number are on the front of your ID card. Important phone numbers are found on the back. Please call PHP FamilyCare MIChild s Customer Service Department if your PHP FamilyCare MIChild ID card has: k Been lost or stolen k An error on it Carry your PHP FamilyCare MIChild ID card and show your card each time you receive services. Letting someone else use your ID card can result in the loss of your health care coverage with PHP FamilyCare MIChild. What if I have a change in my Insurance coverage? Anytime your other insurance coverage changes, you must notify Michigan Enrolls at What if there is a change in my family situation? Notify Michigan Enrolls at k If your family size changes. k If you need to add a newborn. k If you move out of the area. If you lose MIChild eligibility If you lose your State MIChild eligibility, you will be disenrolled from PHP FamilyCare MIChild. Is there any other way I could lose my PHP FamilyCare MIChild eligibility? k You let someone else use your PHP FamilyCare MIChild ID card for services. k You cannot maintain a good relationship with your doctor. An example of a bad relationship is repeatedly going to an emergency room for non-emergency care. k You are abusive and/or threatening to your doctor and/or PHP FamilyCare MIChild staff. k You abuse your drug benefit. We will talk to you when these things happen. We will only ask that you be disenrolled if we can t solve the problem. If you do not agree with us, you may start the Member Appeal process by calling Customer Service at Please call us at the Customer Service number listed below or on your ID card. PHP FamilyCare MIChild s Customer Service hours are from 8:30 am to 5:30 pm Monday through Friday. There is always a nurse on call 24 hours a day to answer your questions. 20 phpmm.org

22 Important Phone Numbers PHP FamilyCare MIChild Customer Service Toll Free Local Michigan ENROLLS (Enrollment Issues) Toll Free COMMUNICATION SERVICES TTY/TDD Services This service can be used by a person who is deaf, hard-of-hearing or has problems speaking. You must have a device with a keyboard called a Teletypewriter (TTY) or a Telecommunications Device for the Deaf (TDD). If you have one of these special devices, call to reach the Relay Center. The Relay Center will help you call the PHP FamilyCare MIChild Customer Service Department. AT&T Language Line Service If you have trouble speaking English, you can still call the PHP FamilyCare MIChild Customer Service Department. We use AT&T Language Line Services. Tell us what language you speak best and we will have an interpreter translate your questions for us and explain the answers to you. Interpretation Services If you speak another language or have trouble understanding your doctor, call the PHP FamilyCare MIChild Customer Service Department at for help. CONFIDENTIALITY Routine Consent PHP FamilyCare MIChild members give their routine consent to release personal data including: k Last name k Address k Referrals k Claims k ID number PHP FamilyCare MIChild may use this data to: k Arrange for your health care k Answer agency reviews k Gather data for surveys

23 k Enroll you in the plan k Pay claims k Other uses as defined by PHP FamilyCare MIChild Special Consent PHP FamilyCare MIChild must have your special consent to release data to individuals or others for purposes other than those covered under routine consent. If you cannot give consent, PHP FamilyCare MIChild will get it from your parent/guardian, Patient Advocate or next of kin. PHP FamilyCare MIChild will release data without your consent only if allowed or required by law. Data may be used for research without your consent. You will not be identified. PHP FamilyCare MIChild may share your data with MIChild as required by the State contract. Anyone who has cause to review your data will 1) sign a statement agreeing to keep it private, and 2) look at the data in a private place. Anyone contracted or employed by PHP FamilyCare MIChild who has a need to review your data will secure your data at their work place. Contact us if you would like to review your data or change your administrative data. If you have questions contact us toll free at How to contact us if there is a problem If you have a question, concern or complaint, call PHP FamilyCare MIChild s Customer Service Department at Our Customer Service staff will try very hard to respond to your questions and concerns right away. APPEAL PROCESS We hope that you are always satisfied with the service you receive from us. We know, however, that from time to time you may have a problem or concern that you want us to address. If you have a question, concern or complaint, call PHP FamilyCare MIChild s Customer Service Department at the telephone number shown on your PHP FamilyCare MIChild ID card. Our Customer Service staff will try very hard to respond to your questions and concerns right away. If you are still not satisfied, you can take the following steps however, you must file your appeal within 90 days following an adverse determination notice. Step 1 k Write or call PHP FamilyCare MIChild and explain your dissatisfaction. We will help you fill out the form if necessary. You may also file a complaint directly with the State of Michigan. k Reviewers at PHP Family Care who review appeals are different from the person who made the first decision. Such a person also does not report to anyone who makes decisions about medical care. 22 phpmm.org

24 k Medical appeals are reviewed by reviewers who are experts in the condition you are asking about. k At any time during the appeal process, you may choose someone to act on your behalf. This may be a doctor. You will need to tell us in writing who you want. If an appeal is received from the person you choose and not you, we must have your written approval. The timeline for the appeal will not start until we receive it. k PHP FamilyCare MIChild will tell you the date and time of an Appeal Committee hearing. You or your representative may attend in person or by telephone. k If you or your representative are unable to attend the Appeal Committee hearing in person or by telephone, you may ask to delay the hearing. You can delay the hearing up to 10 days. A written request must be sent to PHP FamilyCare MIChild if you wish to delay the hearing. Otherwise, PHP FamilyCare MIChild will make a final decision on your appeal after reviewing the information available at the time of the hearing. k PHP FamilyCare MIChild will send you a letter within 30 days from the date of your appeal, unless you asked to delay the hearing. The letter will tell you PHP FamilyCare MIChild s final decision. Step 2 If you are not happy with PHP FamilyCare MIChild s final decision, you have the right to an external review by the Department of Insurance and Financial Services (DIFS). For information and forms, contact DIFS. k PHP FamilyCare MIChild will provide a copy of the DIFS Request for External Review Form. k You must send your request for an external review within 60 days from the date you receive PHP FamilyCare MIChild s decision. You must finish the PHP FamilyCare MIChild appeal process before asking for an external review by DIFS. k PHP FamilyCare MIChild will continue coverage if: The appeal is filed on or before the later of either 10 days of the mailing of the adverse benefit determination notice or the intended effective date of the denial. If the appeal involves the termination, suspension, or reduction of a previously authorized course of treatment. The services were ordered by an authorized provider. The authorization period has not expired. You request an extension of benefits. k If PHP FamilyCare MIChild continues or reinstates your benefits while your appeal is pending, we will continue your benefits until one of the following actions take place. You cancel the appeal

25 The authorization expires or authorization limits are met. If PHP FamilyCare MIChild reverses the adverse action decision or the decision is reversed, we will pay for services provided while the appeal is pending. We will also authorize or provide disputed services quickly and as your health condition requires. ~ If the denial is upheld, you may be required to pay the cost of the services. ~ PHP FamilyCare MIChild will inform you of our decision in writing. External Review by the Michigan Department of Insurance and Financial Services (DIFS) Healthcare Appeals Section Office of General Counsel P.O. Box Lansing MI Fax: Website: Exceptions for Urgent Situations The above appeal procedures do not apply if you have a dispute with PHP FamilyCare MIChild over an upcoming health service, which in the opinion of a doctor, needs to be treated as an urgent situation due to a risk to your life or health. In urgent situations: k The doctor needs to notify PHP FamilyCare MIChild, orally or in writing, to confirm that an urgent situation exists and special procedures for appeal are needed. You or your doctor must file your urgent appeal within 10 days of the adverse determination notice. k If your situation is not considered urgent, PHP FamilyCare MIChild will let you know this and transfer your request to our standard appeal process. k PHP FamilyCare MIChild will tell you and the doctor its initial decision within two (2) days after the doctor notifies PHP FamilyCare MIChild of the urgent situation. If our initial decision is not in writing, we will put it in writing after speaking with you. For urgent situations, you may ask for a review by DIFS. You have 10 days after receipt of PHP FamilyCare MIChild s determination of your expedited appeal to request this review. OTHER INFORMATION New Technology We know that it is important to stay up to date with what is available in health care. PHP FamilyCare MIChild evaluates new medical technology by: 24 phpmm.org

26 k Reviewing research about new technology k Reviewing the benefits of using the technology k Deciding if it should be included as a benefit Advance Directives You have a right to make decisions about your medical care. You have a right to accept or refuse medical or surgical treatment. You also have a right to plan and direct the types of health care you may receive if you become unable to express your wishes. This is called Advance Directives. You can let your doctor know about your wishes by filling out an Advance Directives form for health care. A complete description of Advance Directives can be found in your PHP FamilyCare MIChild Member Packet. You may also call the Customer Service Department or your PCP for a copy. For complaints about how your provider follows your wishes write or call: Bureau of Health Professions (BHP), Complaint & Allegation Division P.O. Box Lansing, MI or bhpinfo@michigan.gov The BHP Complaint & Allegation website is (Click on file a complaint ). For complaints about how your health plan follows your wishes write or call: DIFS Toll free at or Patient Bill of Rights We believe that you should know about your health plan. A Michigan law called the Patient Bill of Rights states the following: k The subscriber contract will explain your benefits including: Emergency services How to file a grievance Out of area services All health services including pharmacy Any out-of-pocket expenses you may have k Intractable pain is when the cause of the pain cannot be removed or treated. If you believe that you may have this pain, you should talk to your PCP. Your PCP will examine you and treat you. He/she may refer you to a specialist if necessary

27 k You have a right to receive the following: Provider Directory, which includes names of providers, hospitals and how to change doctors. Please call PHP Customer Service at to get a copy or visit our website: www. phpmichigan.com. Information about the credentials of our doctors including degrees, hospital privileges, and certification date. The process to find out about any discipline regarding your doctor. Information about any requirements, limitations or exclusions in your benefits, including information about our recommended list of drugs. Summary information about the financial arrangements between PHP FamilyCare MIChild and any provider. This includes how the provider is paid and if the payment is based on quality or patient satisfaction. Summary information on PHP FamilyCare MIChild member satisfaction statistics. Who to call If you would like any information on Patient Bill of Rights, call the PHP FamilyCare MIChild Customer Service Department toll free at HELP US STOP MEMBER FRAUD AND ABUSE PHP FamilyCare MIChild has started a program to help stop member fraud and abuse. What is fraud and abuse? Fraud is when someone lies or doesn t tell the truth and then they benefit from it. Examples of Fraud are: k Using an expired ID card k A PCP discharging members from their care because of the member s health k Allowing a friend or family member to use your ID card k Changing a prescription k Trying to get a refill that is not allowed on a prescription k Telling a lie to get medical or pharmacy services k Being billed for services when no services were provided 26 phpmm.org