FIDELIS SECURELIFE MEDICARE-MEDICAID PLAN (MMP) 2016 Summary f Benefits H9487_SB16_Accepted_08182015
Fidelis SecureLife (Medicare-Medicaid Plan) Summary f Benefits H9487_SB16_Accepted_08182015 This is a summary f health services cvered by Fidelis SecureLife (Medicare-Medicaid Plan) fr January 1, 2016. This is nly a summary. Please read the Member Handbk fr the full list f benefits. Fidelis SecureCare f Michigan, Inc., is a health plan that cntracts with bth Medicare and Michigan Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under Fidelis SecureLife (Medicare-Medicaid Plan) yu can get yur Medicare and Michigan Medicaid services in ne health plan. A Care Crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, restrictins, and patient pay amunts may apply. This means that yu may have t pay fr sme services and that yu need t fllw certain rules t have Fidelis SecureLife (MMP) pay fr yur services. Fr mre infrmatin, call Fidelis SecureLife (MMP) Member Services r read the Fidelis SecureLife (MMP) Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. Yu can get this infrmatin fr free in ther languages. Call 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Yu can als get this infrmatin fr free in ther frmats, such as large print, braille, r audi. Call 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711.The call is free. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 1
Fidelis SecureLife (MMP): Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a Fidelis SecureLife (MMP) Care Crdinatr What are lng term supprts and services Will yu get the same Medicare and Michigan Medicaid benefits in Fidelis SecureLife (MMP) that yu get nw Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng term services, and ther prviders. It als has Care Crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A Fidelis SecureLife (MMP) Care Crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng term supprts and services are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. Yu will get yur cvered Medicare and Michigan Medicaid benefits directly frm Fidelis SecureLife (MMP). Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. If yu are currently receiving services fr mental health, substance use, r intellectual/develpmental disability needs, yu will cntinue t receive these services the same way yu d nw. When yu enrll in Fidelis SecureLife (MMP), yu and yur care team will wrk tgether t develp an Individual Integrated Care and Supprts Plan (IICSP) t address yur health and supprt needs. Yu can keep seeing yur dctrs and getting yur current services fr up t 90 days, r 180 days depending n the service, while yur IISCP is being cmpleted. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Fidelis SecureLife (MMP) des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Fidelis SecureLife (MMP) t cver yur drug, if medically necessary. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 2
Fidelis SecureLife (MMP): Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw What happens if yu need a service but n ne in Fidelis SecureLife (MMP) s netwrk can prvide it Where is Fidelis SecureLife (MMP) available D yu pay a mnthly amunt (als called a premium) under Fidelis SecureLife (MMP) What is prir authrizatin Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Fidelis SecureLife (MMP) and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Fidelis SecureLife (MMP) s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Fidelis SecureLife (MMP)'s plan. If yu receive emergency care at an ut-f-netwrk hspital and need inpatient care after yur emergency cnditin is stabilized, yu must return t a netwrk hspital in rder fr yur care t cntinue t be cvered. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Fidelis SecureLife (MMP) s Prvider and Pharmacy Directry. If Fidelis SecureLife (MMP) is new fr yu, yu can cntinue seeing the dctrs yu g t nw while yur IICSP is being develped. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Fidelis SecureLife (MMP) will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Macmb and Wayne Cunties, Michigan Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t Fidelis SecureLife (MMP) fr yur health cverage. Prir authrizatin means that yu must get apprval frm Fidelis SecureLife (MMP) befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Fidelis SecureLife (MMP) may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r ut-f-area dialysis services, yu dn't need t get apprval first. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 3
Fidelis SecureLife (MMP): Summary f Benefits Frequently Asked Questins (FAQ) What is a referral Whm shuld yu cntact if yu have questins r need help Answers A referral means that yur primary care prvider must give yu apprval t see smene that is nt yur primary care prvider. If yu dn t get apprval, Fidelis SecureLife (MMP) may nt cver the services. There are certain specialists in which yu d nt need a referral, such as wmen s health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. If yu have general questins r questins abut ur plan, services, service area, billing, r member cards, please call Fidelis SecureLife (MMP) Member Services: CALL 1-844-239-7387 Calls t this number are free. Hurs are frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Hurs are frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 4
Fidelis SecureLife (MMP): Summary f Benefits Frequently Asked Questins (FAQ) Whm shuld yu cntact if yu have questins r need help (cntinued) Answers If yu have questins abut yur health, please call the 24 Hur Nurse Advice line: CALL 1-844-239-7387 Calls t this number are free. Hurs are 24 hurs, 7 days a week. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Hurs are 24 hurs, 7 days a week. If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line fr the lcal Pre-paid Inpatient Health Plan (PIHP): In Macmb Cunty, call 1-855-927 4747. In Wayne Cunty, call 1-800-241-4949. If yu have questins abut behaviral health services and resurces, please call the PIHP General Infrmatin Line: CALL In Macmb Cunty, call 1-855-996-2264. In Wayne Cunty, call 1-800-241-4949. Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. TTY In Macmb Cunty, call 711. In Wayne Cunty, call 1-866-870-2599. This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 24 hurs a day, seven days a week. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 5
Fidelis SecureLife (MMP): Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Yu want t see a dctr Visits t treat an injury r illness $0 Nne. Wellness visits, such as a physical $0 Nne. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Transprtatin t a dctr s ffice $0 Fr Plan-apprved lcatins nly. Cntact yur Care Crdinatr fr details. Specialist care $0 Referral and prir authrizatin required. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 Nne. $0 Nne. Yu need medical tests Lab tests, such as bld wrk $0 Nne. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 Referral and prir authrizatin required. $0 Referral and prir authrizatin may be required. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 6
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Yu need drugs t treat yur illness r cnditin Services yu may need Yur csts fr in-netwrk prviders Generic drugs (n brand name) $0 cpay fr a 30 day supply. $0 cpay fr a 90 day supply. Brand name drugs $0 cpay fr a 30 day supply. $0 cpay fr a 90 day supply. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) There may be limitatins n the types f drugs cvered. Please see Fidelis SecureLife (MMP) s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin r may require that yu try a different drug first. An extended-day supply f drugs is available thrugh bth retail and mail rder pharmacies. Please refer t ur Drug List t view thse drugs available fr an extendedday supply. There may be limitatins n the types f drugs cvered. Please see Fidelis SecureLife (MMP) s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin r may require that yu try a different drug first. An extended-day supply f drugs is available thrugh bth retail and mail rder pharmacies. Please refer t ur Drug List t view thse drugs available fr an extendedday supply. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 7
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see Fidelis SecureLife (MMP) s List f Cvered Drugs (Drug List) fr mre infrmatin. Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. Prir authrizatin required. Yu need therapy after a strke r accident Yu need emergency care Occupatinal, physical, r speech therapy $0 Referral and prir authrizatin required. Emergency rm services $0 Emergency rm services d nt require a referral r prir authrizatin and can be prvided at an in-netwrk r ut-f-netwrk facility. Emergency rm services are nt cvered utside the U.S. and its territries except under limited circumstances. Ambulance services $0 Ambulance services fr emergencies d nt require a referral r prir authrizatin and can be prvided by an in-netwrk r ut-fnetwrk prvider. Prir authrizatin is required fr ambulance services in nn-emergency situatins. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 8
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Urgent care $0 Urgent care services d nt require a referral r prir authrizatin. Urgent needed care may be furnished by innetwrk prviders r by ut-f-netwrk prviders if netwrk prviders are temprarily unavailable r inaccessible. Yu need hspital care Hspital stay $0 Prir authrizatin required, except in an emergency. Yu need help getting better r have special health needs Dctr r surgen care $0 During an authrized hspital stay, dctr and surgen care are cvered. Rehabilitatin services $0 Prir authrizatin required. Medical equipment fr hme care $0 Prir authrizatin required. Additinal Durable Medical Equipment is prvided in accrdance with published Michigan Medicaid plicy. Requirements fr referral, physician rder and assessment apply alng with limitatins n replacement and repair. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 9
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Skilled nursing care $0 Prir authrizatin required. Additinal Durable Medical Equipment is prvided in accrdance with published Michigan Medicaid plicy. Requirements fr referral, physician rder and assessment apply alng with limitatins n replacement and repair. Yu need eye care Eye exams $0 A rutine eye exam is cvered nce every year. N referral r prir authrizatin is needed fr a rutine eye exam. A referral and a prir authrizatin are required t receive care frm a specialist fr injuries r diseases f the eye. Certain tests and prcedures may als require referrals and prir authrizatin. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 10
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Glasses $0 The plan will pay fr an initial pair f eye glasses. Replacement glasses are ffered nce every year. The plan will pay fr cntact lenses fr peple with certain cnditins. The plan will pay fr ne pair f glasses r cntact lenses after each cataract surgery when the dctr inserts an intracular lens. (If yu have tw separate cataract surgeries, yu must get ne pair f glasses after each surgery. Yu cannt get tw pairs f glasses after the secnd surgery, even if yu did nt get a pair f glasses after the first surgery.) The plan will als pay fr crrective lenses, frames, and replacements if yu need them after a cataract remval withut a lens implant. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 11
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Yu need dental care Services yu may need Dental check-ups, exams, x-rays, cleanings, fillings, tth extractins, dentures and partial dentures Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 The plan cvers an ral exam and a cleaning (prphylaxis) nce every 6 mnths. The plan cvers rutine dental X-rays (bitewing radigraphs) nce every 12 mnths. N referral r prir authrizatin is required fr preventive dental services. Prir authrizatin is required fr nnpreventive (cmprehensive) dental services. Rt canals and crwns are nt cvered. Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Hearing screenings $0 Rutine hearing exams are nt cvered. Screenings t help diagnse injuries r diseases are cvered. A diagnstic hearing screening requires a referral and a prir authrizatin. Hearing aids $0 Nt cvered. Services t help manage yur disease $0 Referral and prir authrizatin are required fr diabetes self-management training and kidney disease educatin services. The plan als ffers additinal disease management services fr certain chrnic cnditins. Cntact Member Services fr mre infrmatin. A referral and prir authrizatin may be required. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 12
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Yu have a mental health cnditin Yu have cncerns related t substance use Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Diabetes supplies and services $0 Prir authrizatin required. Behaviral health services $0 Prvided thrugh the Pre-paid Inpatient Health Plan (PIHP) Prir authrizatin required. Substance use services $0 Prvided thrugh the Pre-paid Inpatient Health Plan (PIHP) Prir authrizatin required. Wheelchairs $0 Referral and prir authrizatin required. Canes $0 Referral and prir authrizatin required.. Crutches $0 Referral and prir authrizatin required. Walkers $0 Referral and prir authrizatin required. Oxygen $0 Referral and prir authrizatin required.. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 13
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Yu need help living at hme Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Meals brught t yur hme $0 Services are nly available t individuals n the MI Health Link 1915(c) waiver. State eligibility requirements apply. Limited t 2 meals per day. Referral and prir authrizatin required. Hme services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access $0 Services are nly available t individuals n the MI Health Link 1915 (c) waiver. State eligibility requirements apply. Referral and prir authrizatin required. $0 Services are nly available t individuals n the MI Health Link 1915 (c) waiver. State eligibility requirements apply. Referral and prir authrizatin required. Persnal care services (Yu may be able t emply yur wn persnal care assistant. Call Member Services fr mre infrmatin.) $0 Referral and prir authrizatin required. Hme health care services $0 Referral and prir authrizatin required. Adult day services r ther supprt services $0 Services are nly available t individuals n the MI Health Link 1915 (c) waiver. State eligibility requirements apply. Referral and prir authrizatin required. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 14
Fidelis SecureLife (MMP): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need a place t live with peple available t help yu Nursing hme care A patient pay amunt may be required fr nnskilled days f service. Services are nly available t individuals wh meet the Michigan Medicaid Nursing Facility Level f Care Determinatin standards. Referral and prir authrizatin required. Yur caregiver needs sme time ff Respite care $0 Prir authrizatin required. Limited t 14 vernight stays in 365-day perid. Additinal respite care services are available t individuals n the MI Health Link 1915 (c) waiver. State eligibility requirements apply. A referral and a prir authrizatin are required fr additinal respite care services. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 15
Fidelis SecureLife (MMP): Summary f Benefits Other services that Fidelis SecureLife (MMP) cvers This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services. Other services cvered by Fidelis SecureLife (MMP) Yur csts fr in-netwrk prviders Adaptive medical equipment and supplies $0. Assistive technlgy (devices) $0. Assistive technlgy (van lifts and tie dwns) $0. Cmmunity transitin services $0. Expanded cmmunity living supprts $0. Fiscal intermediary services $0. Incntinence supplies $0. Nn-medical transprtatin $0. Persnal emergency respnse system $0. Preventive nursing services $0. Private duty nursing services $0. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 16
Fidelis SecureLife (MMP): Summary f Benefits Benefits cvered utside f Fidelis SecureLife (MMP) This is nt a cmplete list. Call Member Services t find ut abut ther services nt cvered by Fidelis SecureLife (MMP) but available thrugh Medicare r Michigan Medicaid. Other services cvered by Medicare r Michigan Medicaid Prepaid Inpatient Health Plan (PIHP) services: Inpatient behaviral health care, utpatient substance use disrder services, and partial hspitalizatin services Yur csts $0 If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 17
Fidelis SecureLife (MMP): Summary f Benefits Services that Fidelis SecureLife (MMP), Medicare, and Michigan Medicaid d nt cver This is nt a cmplete list. Call Member Services t find ut abut ther excluded services. Services nt cvered by Fidelis SecureLife (MMP), Medicare, r Michigan Medicaid Acupuncture Chirpractic care (except manual manipulatin fr certain apprved cnditins) Csmetic surgery r csmetic wrk Elective r vluntary enhancement prcedures r services Experimental medical and surgical treatments, items and drugs, unless cvered by Medicare r under a Medicare-apprved clinical research study Full-time nursing care in yur hme Rutine hearing exams, hearing aids, r exams t fit hearing aids Hspice services Naturpath services Orthpedic shes (unless included with a leg brace r fr diabetic ft disease). Supprtive devices fr feet (except fr rthpedic r therapeutic shes fr peple with diabetic f disease) Persnal items in yur hspital r nursing hme rm Private duty nurses except as cvered under waiver services. Private rm in hspital r nursing facility, except when it is medically needed Reversal f sterilizatin prcedures, sex change peratins, and nnprescriptin cntraceptive supplies Rutine ft care, except fr the limited cverage prvided accrding t Medicare guidelines Services nt cnsidered reasnable and necessary Services prvided t veterans in VA facilities, except fr emergency services Surgical treatment fr mrbid besity, except when it is medically needed and Medicare pays fr it Services received utside the United States r its territries Services fr treatment f infertility Services received frm prviders wh are nt eligible t participate in Medicare and/r Michigan Medicaid Visin prcedures such as LASIK If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 18
Fidelis SecureLife (MMP): Summary f Benefits Yur rights as a member f the plan As a member f Fidelis SecureLife (MMP), yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right: Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: T get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English T get infrmatin in ther frmats (e.g., large print, braille, audi) T be free frm any frm f restraint r seclusin T nt be billed by netwrk prviders Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right: Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right: T chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time T see a wmen s health care prvider withut a referral T get yur cvered services and drugs quickly T knw abut all treatment ptins, n matter what they cst r whether they are cvered T refuse treatment, even if yur dctr advises against it T stp taking medicine T ask fr a secnd pinin. Fidelis SecureLife (MMP) will pay fr the cst f yur secnd pinin visit. T get medical care timely T get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act T have interpreters t help with cmmunicatin with yur dctrs and yur health plan. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 19
Fidelis SecureLife (MMP): Summary f Benefits Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right: Yu have a right t cnfidentiality and privacy. This includes the right: T get emergency services withut prir apprval in an emergency T see an ut f netwrk urgent r emergency care prvider, when necessary T ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. T have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right: T file a cmplaint r grievance against us r ur prviders T ask fr a state fair hearing T get a detailed reasn fr why services were denied Fr mre infrmatin abut yur rights, yu can read the Fidelis SecureLife (MMP) Member Handbk. If yu have questins, yu can als call Fidelis SecureLife (MMP) Member Services. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 20
Fidelis SecureLife (MMP): Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Fidelis SecureLife (MMP) shuld cver smething we denied, call Fidelis SecureLife (MMP) at 1-844 239-7387 (TTY: 711). Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Fidelis SecureLife (MMP) Member Handbk. Yu can als call Fidelis SecureLife (MMP) Member Services. Fidelis SecureLife (MMP) ATTN: Appeals and Grievances 7700 Frsyth Blvd. St. Luis, MO 63105 Phne: 1-844-239-7387 (TTY: 711) Fax: 1-844-273-2671 Hurs f peratin are frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Fidelis SecureLife (MMP) Member Services. Phne numbers are n the cver f this summary. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users shuld call 1-877-486-2048. Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Or, cntact the Michigan Attrney General s Health Care Fraud Divisin Htline by phne at (800) 24-ABUSE [800-242-2873], by e-mail at hcf@michigan.gv r use the n-line Michigan Medicaid Fraud Cmplaint Frm fund at http://www.michigan.gv/ag/0,1607,7-164 17331-46928--,00.html. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 21
Fidelis SecureLife (MMP): Summary f Benefits Multi-Language Interpreter Services English: We have free interpreter services t answer any questins yu may have abut ur health r drug plan. T get an interpreter, just call us at 1-844-239-7387. Smene wh speaks English/Language can help yu. This is a free service. Spanish: Tenems servicis de intérprete sin cst algun para respnder cualquier pregunta que pueda tener sbre nuestr plan de salud medicaments. Para hablar cn un intérprete, pr favr llame al 1-844-239-7387. Alguien que hable españl le pdrá ayudar. Este es un servici gratuit. Chinese Mandarin: 葩 Ẕ 裊 簯 聂 峡 蠿 鎻 孹 膞 ᖎ 裝 ᝍ 豻 繆 ය 虚 筶 笵 贍 北 肵 膈 昑 蠿 螙 谩 蝀 斖 ૡ 蔒 籂 ᝍ 菈 蘶 觧 鎻 孹 膞 実 講 䓝 1-844-239 7387ૡ 葩 Ẕ 蠿 襦 肫 簴 蟇 蝸 髠 蜻 ᖎ 裝 ᝍૡ 征 萙 螐 校 聂 峡 膞 ૡ Chinese Cantnese: ᝍ 繘 葩 肧 蠿 筶 笵 贍 蓌 肵 膈 貚 竑 縑 褌 蛞 蝀 肪 Ⅽ 觧 葩 肧 裊 簯 聂 舫 蠿 鎻 蔮 膞 肏 ૡ 蔒 菈 鎻 蔮 膞 肏 誂 講 衴 1-844-239-7387ૡ 葩 肧 筄 襦 肫 蠿 蝸 蚗 蟧 葼 蜻 Ⅽᝍ 裊 簯 鎩 裝 ૡ 蠲 萙 螐 豮 聂 舫 膞 肏 ૡ Tagalg: Mayrn kaming libreng serbisy sa pagsasaling-wika upang masagt ang anumang mga katanungan niny hinggil sa aming planng pangkalusugan panggamt. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-844-239 7387. Maaari kayng tulungan ng isang nakakapagsalita ng Tagalg. It ay libreng serbisy. French: Nus prpsns des services gratuits d'interprétatin pur répndre à tutes vs questins relatives à ntre régime de santé u d'assurance-médicaments. Pur accéder au service d'interprétatin, il vus suffit de nus appeler au 1-844-239 7387. Un interlcuteur parlant Français purra vus aider. Ce service est gratuit. Vietnamese: Chúng tôi có dʃch vʝ thông dʃch miɽn phí ÿɻ trɛ lʕi các câu hʇi vɹ chʉɂng sʡc khʇe và chʉɂng trình thuʉc men. Nɷu quí vʃ cɟn thông dʃch viên xin gʅi 1-844-239-7387 sɵ có nhân viên nói tiɷng Viɿt giúp ÿʙ quí vʃ. Ĉây là dʃch vʝ miɽn phí. German: Unser kstenlser Dlmetscherservice beantwrtet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dlmetscher erreichen Sie unter 1-844-239-7387. Man wird Ihnen drt auf Deutsch weiterhelfen. Dieser Service ist kstenls. H9487_MultiLang16_Accepted_07212015 If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 22
Fidelis SecureLife (MMP): Summary f Benefits Krean: アンヘ ア0 㦮 䠮 0 㟓 䛞 䠮 㠦 ὖ 䞲 㰞 ⶎ 㠦 䟊 Ⰲἶ 㧦 ⶊ 䐋 㡃 da 㓺 㩲 Ὃ 䞮 ἶ 㧞 㔋. 䐋 㡃 da 㓺 㧊 㣿 䞮 Ⳋ 㩚 䢪 1-844-239-7387 㦒 ⶎ 㦮 䟊 㭒 㕃 㔲 㡺. 䞲 ῃ 㠊 䞮 0 㧦 Ṗ 㢖 Ⰺ ộ 㧛. 㧊 da 㓺 0 ⶊ 㤊 㡗. Russian: ǬȘȒȏ Ț ȉȇș ȉȕȏȕȏȑȕțș ȉȕȗȗȕșȣ ȕșȕȕșȏșȍȓȣȕȕ ȘșȗȇȜȕȉȕȊȕ ȏȓȏ ȓȍȋȏȑȇȓȍȕșȕȕȋȕ ȖȒȇȔȇ, ȉȣ ȓȕȍȍșȍ ȉȕșȗȕȓȣȏȕȉȇșȣșȧ Ȕȇȟȏȓȏ ȈȌȘȖȒȇșȔȢȓȏ ȚȘȒȚȊȇȓȏ ȖȌȗȌȉȕȋȞȏȑȕȉ. ǾșȕȈȢ ȉȕșȗȕȓȣȏȕȉȇșȣșȧ ȚȘȒȚȊȇȓȏ ȖȌȗȌȉȕȋȞȏȑȇ, ȖȕȎȉȕȔȏșȌ Ȕȇȓ Ȗȕ șȍȓȍțȕȕț 1-844-239-7387. ǩȇȓ ȕȑȇȍȍș ȖȕȓȕȠȣ ȘȕșȗȚȋȔȏȑ, ȑȕșȕȗȣȑ Ȋȕȉȕȗȏș Ȗȕ-pȚȘȘȑȏ. ǫȇȕȕȇȧ ȚȘȒȚȊȇ ȈȌȘȖȒȇșȔȇȦ. Arabic: ΎϧΑ ϝύληϻ ϯϭγ ϙϳϡϋ αϳϟ ˬϱέϭϓ ϡοέηϣ ϰϡϋ ϝϭλσϡϟ.ύϧϳωϟ ΔϳϭΩϷ ϝϭωο ϭ ΔΣλϟΎΑ ϕϡόηη ΔϠγ ϱ ϥϋ ΔΑΎΟϺϟ ΔϳϧΎΟϣϟ ϱέϭϔϟ ϡοέηϣϟ ΕΎϣΩΧ ϡωϙϧ Ύϧϧ ΔϳΑέόϟ ΙΩΣΗϳ Ύϣ ιχη ϡϭϙϳγ.7837-932-448-1 ϰϡϋ ΔϳϧΎΟϣ ΔϣΩΧ ϩϋϫ.ϙηωϋύγϣα. Italian: È dispnibile un servizi di interpretariat gratuit per rispndere a eventuali dmande sul nstr pian sanitari e farmaceutic. Per un interprete, cntattare il numer 1-844-239-7387. Un nstr incaricat che parla Italianvi frnirà l'assistenza necessaria. È un servizi gratuit. Prtugués: Dispms de serviçs de interpretaçã gratuits para respnder a qualquer questã que tenha acerca d nss plan de saúde u de medicaçã. Para bter um intérprete, cntacte-ns através d númer 1-844-239-7387. Irá encntrar alguém que fale idima Prtuguês para ajudar. Este serviç é gratuit. French Crele: Nu genyen sèvis entèprèt gratis pu repnn tut kesyn u ta genyen knsènan plan medikal swa dwòg nu an. Pu jwenn yn entèprèt, jis rele nu nan 1-844-239-7387. Yn mun ki pale Kreyòl kapab ede w. Sa a se yn sèvis ki gratis. If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 23
Fidelis SecureLife (MMP): Summary f Benefits Plish: UmĪliwiamy bezpáatne skrzystanie z usáug táumacza ustneg, który pmīe w uzyskaniu dpwiedzi na temat planu zdrwtneg lub dawkwania leków. Aby skrzystaü z pmcy táumacza znająceg jċzyk plski, naleīy zadzwniü pd numer 1-844-239-7387. Ta usáuga jest bezpáatna. Japanese: ᙜ 艧 筶 笵 筶 笵 膈 㝤 谎 ฎ 脙 ၥၷႁ 㛵 ရ 觐 肪 繆 ရထ ૠ 肚 羌 讈 ヂ၃ 䞊 ၡ၇ ယဎ ဎૡ 讈 ヂ ဢ 虑 聑 ရૠ 1-844-239-7387 衴 贬 ૡ 螔 膩 蓳 ဢ 贬 蝸 螿 覃 蚠 ဎૡလ 肚 羌 ၃ 䞊 ၡ၇ૡ If yu have questins, please call Fidelis SecureLife (MMP) at 1-844-239-7387 frm 8 a.m. t 8 p.m., seven days a week. On weekends and federal hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. TTY users call 711. The call is free. Fr mre infrmatin, visit www.fidelissc.cm/mmp. 24
800 Twer Drive Suite 200 Try, MI 48098 1-844-239-7387 TTY: 711 www.fidelissc.cm/mmp 2015 Fidelis SecureCare. All rights reserved.