Member Handbook
WELCOME...3 MEMBER RIGHTS & RESPONSIBILITIES...4 Membership Rights...4 Membership Responsibilities...5 YOUR SPARROW PHP 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?...6 How do I change my PCP?...7 When do I call my PCP?...7 How do I make a doctor s appointment?...7 What if I need to change or cancel an appointment?...7 What if I need to see a specialist?...7 Can I go to a Federally Qualified Health Center?...8 Can I continue to see my doctor if they have terminated from Sparrow PHP?...8 What do I do if I have an emergency and I am out of town?...8 How do Sparrow PHP providers get paid?...8 Does my doctor receive any incentives?...8 EMERGENCY AND URGENT CARE...9 What is an emergency?...9 What should I do in an emergency?...9 When should I call 911?...9 How can I reach Sparrow PHP after hours?...9 What is urgent care?...9 COVERED SERVICES...10 Eye Exams and Glasses...10 Durable Medical Equipment...10 Hospice Services...10 Mental Health...10 Pharmacy Benefits...10 Pregnancy Services...11 Maternal Infant Health Program (MIHP)... 11 Women, Infant and Children (WIC) Supplemental Food & Nutrition Program... 11 Early, Periodic Screening Diagnosis and Treatment (EPSDT)... 11 Family Planning Services...11 Sexually Transmitted Disease (STDs) Services... 11 Transportation Services...12 Care Management Program...12 How do you make benefit determinations?... 12 New Technology...13 Substance Use Disorder Services... 13 CUSTOMER SERVICE...14 How can the Customer Service Department help me?... 14 If I move, who should I call?...14 What if I get a bill?...14 What if I have other health care coverage?... 14 1
ENROLLMENT & DISENROLLMENT... 14 What do I do if my family size changes?... 14 How do I add my newborn?...14 What should I do if I move out of the area?... 15 Is there any other way I could lose my Sparrow PHP eligibility?... 15 Important Phone Numbers...15 COMMUNICATION SERVICES...15 TTY/TDD Services...15 AT&T Language Line Service...15 Interpretation Services...15 PRIVACY...16 Routine Consent...16 Special Consent...16 How to contact us if there is a problem... 16 APPEAL PROCESS...16 Exceptions for Urgent Situations... 18 OTHER INFORMATION...19 Advance Directives...19 Patient Bill of Rights...20 Who to Call...20 HELP US STOP MEMBER FRAUD AND ABUSE... 20 What is Fraud and Abuse?...20 FOR OUR SPARROW PHP MEDICAID MEMBERS... 22 Covered Services...22 Early, Periodic Screening Diagnosis and Treatment (EPSDT)... 23 OB/GYN or Pediatrician Care...23 Pediatric Care...23 Child and Adolescent Health Center... 23 SERVICES NOT COVERED BY SPARROW PHP MEDICAID... 23 What happens if I lose my Medicaid eligibility?... 24 FOR OUR CHILDREN WITH SPECIAL HEALTH CARE SERVICES (CSHCS) MEMBERS... 25 Additional Benefits for Medical Health Plan Enrollees with Children s Special Health Care Services...25 SERVICES COVERED BY SPARROW PHP CSHCS... 26 OTHER INFORMATION ABOUT SPARROW PHP CSHCS SERVICES... 27 Information about OB/GYN and Pediatrician Services... 27 Pediatric Care...27 Early, Periodic Screening Diagnosis and Treatment (EPSDT)... 27 Child and Adolescent Health Center... 27 SERVICES NOT COVERED BY SPARROW PHP CSHCS... 28 What Happens with Loss of Medicaid Eligibility?... 28 FOR OUR PHP HEALTHY MICHIGAN PLAN (HMP) MEMBERS... 29 Services Covered...29 Additional Information about HMP Services... 30 Co-Pays for Services...30 SERVICES NOT COVERED BY SPARROW PHP HMP... 31 What Happens if I Lose my Medicaid Eligibility?... 32 2
WELCOME Welcome to Sparrow PHP, part of Sparrow Health System for more than 30 years. We are pleased to provide the services you need, the care you want and the options you deserve through one of our Sparrow PHP Medicaid programs. Sparrow PHP provides health care coverage with personal service and a wide provider network. When you join Sparrow PHP, you must choose a doctor to be your primary care provider (PCP). They will be your partner in health. They help you manage your health care needs. If you need help finding a PCP, a Sparrow PHP Customer Service specialist can help you. Please read the Member Handbook and Certificate of Coverage (COC) inside your member packet. Keep them in a safe place for future use. Both books will help you to understand and use your Sparrow PHP benefits. Sparrow PHP Customer Service is here to help you. We can explain how Sparrow PHP works. We help you get information when you need it. We help you find or change your PCP doctor and update your address. We can also work with other family members or caregivers you identify to assist you with your health care needs. Our goal is to improve the health of our members by offering access to quality, compassionate care and supporting a healthy lifestyle. Welcome to Sparrow PHP. Call our Customer Service Department at: 517-364-8540 or 1-800-661-8299 8:30 am -5:30 pm, Monday-Friday Visit our web site at www.phpmichigan.com Select Sparrow PHP Visit us in person at our office: Sparrow PHP 1400 E Michigan Ave Lansing, MI 48912 3
Sparrow PHP provides health care coverage to people through Medicaid, Children with Special Health Care Services (CSHCS) and Healthy Michigan Program. The following information is for all members of Sparrow PHP. If you are in the Sparrow PHP Medicaid, CSHCS or HMP program please refer to the section specific to your plan for information about your plan. Medicaid see pages 22 through 24 CSHCS see pages 25 through 28 Healthy Michigan Program see pages 29 through 32 MEMBER RIGHTS & RESPONSIBILITIES Membership Rights All Sparrow PHP staff and contracted providers comply with all requirements concerning member rights. Enrollment with Sparrow PHP 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. This includes clear details of how to locate and use them. 4. Receive quality health care as covered under the plan. The services must be 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. Review your medical record with your provider. You have the right to request and review your medical records obtained by Sparrow PHP at no cost. You have the right to correct or amend your medical records. 7. Choose 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. 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. Use of the plan s problem resolution process. This includes the ability to voice complaints, grievances or appeals about PHP or the care provided. Also, without fear of being penalized and or without fear of loss of coverage. 14. Be free from any form of restraint or reclusion. This might be by 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 Sparrow PHP s member rights and responsibilities policies. 4 phpmichigan.com
18. Get a second medical opinion. 19. Get help with any special disability needs. 20. Get help with any special language needs. 21. Know if a co-payment or contribution is required. Membership Responsibilities 1. Select a primary care provider (PCP) from Sparrow PHP s list of providers. Schedule an appointment within 60 days of enrollment with Sparrow PHP and build a relationship with the provider you choose. 2. Obtain all medical care, except in emergencies, or as otherwise stated in the Member handbook, from a plan provider. All visits to non-participating providers must be approved first by Sparrow PHP. 3. Have approval for all hospitalizations. Your doctor will make the plans and contact Sparrow PHP. This does not apply to emergencies or for urgently needed health services. 4. Use Emergency Room (ER) services 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. Make visits with your PCP as far in advance as possible. Call if you are unable to keep an appointment. 6. Carry your Sparrow PHP ID card. Show your Medicaid mihealth card and other health plan cards each time you receive health services. Never let someone else use your cards. 7. Report any lost or stolen health cards. Call Sparrow PHP Customer Service if your health plan ID card is missing. Call the Beneficiary Helpline at 1-800-642-3195 if your mihealth card is missing. 8. Call our Customer Service Department if you have a question about your plan coverage. 9. Promptly apply for Medicare or other insurance when you are able. 10. Notify the plan of any changes. This includes a change in address, family size and marital status. Also if you have other health insurance coverage. 11. Provide complete information about your health and health care to the health plan and your doctor. This helps in the care for you. 12. Work with your PCP to manage your health problems and treatment goals. 13. Follow the steps for care that you agree on with your PCP. 800-661-8299 5
For important information, consumers and providers contact: www.phpmichigan.com (517)364-8567 (866)539-3342 Rx Bin#: 610014 This card does not prove membership nor guarantee coverage Rx Grp: PHPRX Group Number: 10000001 MCD All PHP and PCN providers All other providers send Medical Claims to: send Medical Claims to: GlobalCare, Inc. / PHP Electronic Name: Payor ID: 37330 MEMBER, EDI SAMPLE Payor ID: 07689S PHP PO Box 853936 PO Box 247 Richardson, TX 75086-3936 Alpharetta, GA 30009-0247 If you need emergency services when away from home, YOUR SPARROW PHP I.D. CARD Marketplace-Exclusive-HMO Important Consumer Information For information, go to: www.phpmichigan.com Customer Service: 800-661-8299 517-364-8540 TTY/TD: 800-649-3777 Rx Bin#: 610014 Plan Type: Gold Exclusive Rx Grp: PHPRX Group Number: L0001699 Subscriber Number: 100000080 This card does not prove membership nor guarantee coverage. Name(s): MEMBER, SAMPLE S 00 Important Provider Information Notification as required: 866-203-0618 call GlobalCare (866) 807-6193 or go to www.phpmichigan.com Member Identification card Subscriber Number: 100000010 00 Medical Claims to: Sparrow PHP, PO BOX 853936 Richardson, TX 75085-3936 Your Sparrow PHP ID card is very important. Every person who is covered by Sparrow PHP has his (in MI) or her own Elec. Claim ID card. Payer Your ID#: name 37330 Date Issued: 05/10/2013 Date Issued: 01/28/2015 and member number are on the front of your ID card. Important phone numbers are found on the back. Please call Sparrow PHP s Customer Service Department if your Sparrow PHP ID card has: Important Consumer Information Important Consumer Information Authorization Required For information, go to: www.phpmichigan.com For information, go to: www.phpmichigan.com For inpatient stay, Transplant MiCh services & Customer Service: 800-661-8299 Customer Service: 800-203-9519 Dental services related to an accident. 517-364-8456 call 866-203-0618 for authorization. 517-364-8540 Been lost or stolen An error on it Notify PHP of TTY/TD: 800-649-3777 Rx Bin#: 610014 Rx Bin#: 610014 Plan Type: PPO Emergency Admits: 866-203-0618 Rx Grp: PHPRX Rx Grp: PHPRX Group Number: L0001573 This card does not prove membership nor guarantee coverage. The State Name: of Michigan MEMBER, SAMPLE will also Ssend you a Medicaid mihealth card. Your Medicaid Subscriber Number: eligibility 100000090 Contracted Cofinity providers All other providers Medical Claims to: This card does not prove membership nor guarantee coverage. will be send Medical claims to: GlobalCare, Inc. / PHP updated Electronic Group electronically Payor ID: 38335 Electronic Number: 10000002 each Payor month. ID: 07689 If your Medicaid mihealth Name(s): card is lost or stolen, please report this PHP PO BOX 853936 PO Box 247 MEMBER, SAMPLE S 00 Richardson, TX 75085-3936 Alpharetta, GA 30009-0247 Important Provider Information to Michigan Subscriber ENROLLS Number: at 100000020 1-800-975-7630 To locate in-network Providers & Hospitals or to speak with a Registered Nurse when Notification as required: 866-203-0618 away from home, call GlobalCare at (866) 807-6193 or go to www.cofinity.net Available Carry your PCP Networks Sparrow Name: Outside the Primary Doctor, Network PHP ID Member Service Area: card and A. your Medicaid mihealth card Medical Claims with to: Sparrow you PHP, at all PO BOX times. 853936 Show both PCP Phone: 5175551212 Richardson, TX 75085-3936 ID cards each time you receive services. Letting someone else use your ID card can result in the loss (Outside MI, IN, OH, CO, + AZ) (complementary) Elec. Claim Payer ID#: 37330 Date Issued: 11/08/2013 Date Issued: 01/28/2015 of your health care coverage with Sparrow PHP. Important Consumer Information Authorization Required For information, go to: www.phpmichigan.com For inpatient stay, Transplant HMP services & Customer Service: 800-203-9519 Dental services related to an accident. 517-364-8456 call 866-203-0618 for authorization. Notify PHP of Rx Bin#: 610014 Emergency Admits: 866-203-0618 Rx Grp: PHPRX This card does not prove membership nor guarantee coverage. All PHP and PCN Providers All other providers send Medical Claims to: send Medical claims to: GlobalCare, Inc. / PHP Electronic Name: Payor ID: 37330 MEMBER, Electronic SAMPLE Payor ID: S07689 PHP PO BOX 853936 PO Box 247 Richardson, TX 75085-3936 Alpharetta, GA 30009-0247 To locate Group in-network Number: Providers & Hospitals 10000003 or to speak with a Registered Nurse when away from home, call GlobalCare at (866) 807-6193 or go to www.phpmichigan.com Available Networks Outside the Primary Network Service Area: Subscriber Number: 100000030 00 (in MI) (All other states) Elec. Claim Payer ID#: 37330 Date Issued: 01/30/2015 (complementary) Important Consumer Information For information, go to: www.phpmichigan.com Customer Service: 800-661-8299 517-364-8540 TTY/TD: 800-649-3777 Rx Bin#: 610014 Plan Type: PPO Rx Grp: PHPRX Group Number: L0001573 Subscriber Number: 100000100 This card does not prove membership nor guarantee coverage. Name(s): MEMBER, SAMPLE S 00 Important Provider Information Notification as required: 866-203-0618 Date Issued: 11/08/2013 Medical Claims to: Sparrow PHP, PO BOX 853936 Richardson, TX 75085-3936 6 phpmichigan.com YOUR PRIMARY CARE PROVIDER AND YOU Important Information Plan Desc: MNA Customer Service 517-364-8432 To Locate SPHN Provider: 877-774-6362 Group Number: L0001269 877-275-0076 www.sparrow.org/sphn Choosing your PCP Subscriber Number: 100000040 Rx Bin#: 610014 This card does not prove membership nor guarantee coverage When you join Sparrow PHP, you must pick a PCP. Your PCP is your main doctor. Your PCP will see Rx Grp: PHPRX All contracted SPHN providers All other providers send Medical Claims to: send Medical Claims to: GlobalCare, Inc. you for all your routine health care needs. Your PCP uses Electronic referrals Payor ID: 37330 to manage EDI Payor ID: your 07689 care with specialists, PHP, PO Box 853936 PO Box 247 Name(s): Richardson, TX 75086-3936 Alpharetta, GA 30009-0247 other healthcare MEMBER, SAMPLE providers, S and 00hospitals. How do I choose a PCP? NOTE: For all services that require prior authorization including all inpatient MI All Other States admissions, call PHP Service Company at 517-364-8560 866-203-0618. The Sparrow PHP Provider Directory is available by calling Date Issued: Customer 01/30/2015 Service at 1-800-661-8299. The Provider Directory is mailed within 5 days of your call. You can also look at the Provider Directory on the PHP website: www.phpmichigan.com. Click on Find a Doctor. Customer Service helps you find a Important Consumer Information Important Provider Information For information, go to: www.phpmichigan.com For information, go to: www.phpmichigan.com doctor as well. Customer Service: 517-364-8456 Customer Service: 800-203-9519 877-203-9519 Each family member may have a Group different Number: doctor. L0000264 Below This card does are not prove the membership types nor of guarantee doctors coverage you can pick as your Subscriber Number: 100000050 All contracted PHP and PCN providers All other providers send Medical Claims to: PCP: send Medical Claims to: GlobalCare, Inc. Name(s): MEMBER, SAMPLE S 00 Family/General Practice - doctors who see patients of all ages for general health care. Available Networks Outside the PHP Service Area: Internal Medicine - doctors who treat only adults. They do not do surgery or deliver babies. MI OB/GYN - doctors who care for women and deliver babies. To locate a provider or speak with a Registered Nurse when outside the SPHN service area, call GlobalCare at (866) 807-6193 or (770) 667-0247 Available Networks Outside the Primary Network Service Area: Electronic Payor ID: 37330 EDI Payor ID: 07689 PHP, PO BOX 853936 PO Box 247 Richardson, TX 75085-3936 Alpharetta, GA 30009-0247 To locate a provider or speak with a Registered Nurse when outside the service area, call GlobalCare at (866) 807-6193 or (770) 667-0247 Date Issued: 01/30/2015 All Other States Pediatricians - doctors who see only children to age 16, sometimes 18. Important Consumer Information Important Provider Information For information, go to: www.phpmichigan.com For information, go to: www.phpmichigan.com Customer Service: 866-834-0063 Customer Service: 866-834-0063 517-364-3491 Notify PHP of Emergency Admits: 866-203-0618 Can I have a specialist as a PCP? Plan Type: TPA People with a chronic health condition Group Number: may L0001631 This card does not prove membership nor guarantee coverage need to be seen by a specialist on a regular basis. In some All contracted PHP and PCN providers All other providers send Medical Claims to: Subscriber Number: 100000060 send Medical Claims to: GlobalCare, Inc. cases, it may be better for the specialist to be responsible Electronic Payor for ID: 37330 all of your EDI health Payor ID: 07689 care needs. If you think Name(s): PHP, PO BOX 853936 PO Box 247 Richardson, TX 75085-3936 Alpharetta, GA 30009-0247 you need MEMBER, a specialist SAMPLE as S your PCP, 00 please call the Customer Service Department. To locate in-network Providers & Hospitals or to speak with a Registered Nurse when away from home, call GlobalCare at (866) 807-6193 or go to www.phpmichigan.com Available Networks Outside the PHP Service Area: Date Issued: 01/30/2015
How do I change my PCP? Your PCP is important to your health care. We hope that you pick yours carefully and are happy with your choice. Sometimes there may be a reason why you need to change your PCP. Here are some reasons: You have moved and now your doctor is too far away. You are unhappy with your doctor. Your doctor is no longer a part of Sparrow PHP. When you feel that you need to change to another PCP, you will need to: Pick a new PCP from Sparrow PHP s Provider Directory. Check our website: www.phpmichigan.com or call the Customer Service Department. They will help you find a doctor or mail you a provider directory. Call Sparrow PHP s Customer Service Department to let them know that you have picked a new PCP. Call Sparrow PHP s Customer Service Department if you need help in finding a new PCP. When you change your PCP, it is 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: When you need routine care When you need lab work, tests, etc. As needed to see a specialist When a sudden illness or injury happens (anytime, day or night) To be admitted to a hospital In a life-threatening emergency, call 911. 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 Sparrow PHP member. Tell them why you need to see the doctor. If you are sick or hurt, call your doctor as soon as possible. If you call early in the morning, 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 medicine you are taking. If you have a question and the office is closed, the doctor s answering service refers your call to 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 gives 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. There are some exceptions. The exceptions are listed in this handbook. If you receive medical services without getting a referral from your PCP, you may have to pay for the services. 800-661-8299 7
Your PCP also gives 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 have to pay for them. 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 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 Sparrow PHP? If your PCP is no longer part of the Sparrow PHP network, you will have to pick a new PCP. If you see a specialist who is no longer part of the Sparrow PHP 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: 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 calls Sparrow PHP to make sure you are covered. Call your PCP if you are away from home and become ill. If you are not sick enough to go to the hospital call your PCP. You will be advised to go to an Urgent Care Center or a doctor s office. Your PCP needs to send Sparrow PHP a referral for these services. Routine care is not covered when you are out of the Sparrow PHP Service Area. Your PCP should do all of your routine care. Anytime you are out of the Sparrow PHP Service Area and you have any questions contact us. Read about What is an Emergency and Urgent Care in this handbook. Your PCP may refer you to a provider who is not in the network. The PCP contacts Sparrow PHP to have this approved. Members are allowed to use non-network health care providers when all of the following apply: 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 Sparrow PHP. How do Sparrow PHP providers get paid? Sparrow PHP 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 normally bills. Providers may receive additional payments. Payments 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. 8 phpmichigan.com
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 diability or death. An emergency is defined as a condition that happens suddenly and is so severe that if not treated causes: Serious harm to your health. Serious impairment to your body functions. Serious damage to any body organ or part. The symptoms below can signal an emergency: Choking Pass out Convulsions Strokes Severe Bleeding Broken Bones Heart Attacks/Chest Pain Severe Breathing Problem What should I do in an emergency? 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. Let your PCP know what happened. Do not use the emergency room for an illness that can be treated at your PCP s office. 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 Sparrow PHP after hours? If you cannot reach your PCP, call Sparrow PHP Customer Service. The after-hours answering service takes down your information and assists you or calls the On-Call nurse if necessary. The On Call Nurse calls you back if needed. 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. Ask them to refer you to an Urgent Care Center. Some example of reasons that you might 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 800-661-8299 9
COVERED SERVICES Refer to your Sparrow PHP plan section for a full list of services. For more information on services that are covered and not covered, please read your certificate of coverage. Eye Exams and Glasses Sparrow PHP covers vision services when provided by a Sparrow PHP network provider. Sparrow PHP covers eye exams and certain types of prescription eyeglasses. A routine eye exam every year for members under 21 years of age. One routine eye exam is covered once every two years for member 21 years and over.. One pair of glasses is covered once every year for members under 21 years of age. For members 21 years and over one pair of glasses is covered once every two years. Services needed as a result of eye trauma and eye disease are covered for all members. Replacements and repairs to your glasses are covered as follows: Two pair per year for members under 21 years of age. You do not need a referral from your PCP for a routine eye exam. Eye exams for a medical problem are covered as long as your PCP refers you. Durable Medical Equipment Sparrow PHP covers necessary durable medical equipment such as crutches or wheelchairs. Your PCP must arrange for any durable medical equipment you may need. In most cases, you must get your durable medical equipment from a provider in the Sparrow PHP network. Hospice Services Hospice service is a medical program designed to provide for and relieve the suffering of terminally ill people. Sparrow PHP covers hospice services. Please call your PCP to arrange for hospice services. Mental Health PHP Family Care covers 20 outpatient visits for mental health services. Be sure to go to a mental health provider in our network. You can find this information in the PHP Family Care Provider Directory. Call PHP Family Care Customer Service at 800-661-8299 for help with mental health services. You do not need a referral from your PCP to get mental health services when you go to a mental health provider in the network. If you have a serious mental health illness, you may be referred to the Community Mental Health Services in your county. Pharmacy Benefits Sparrow PHP provides coverage for prescription drugs. Your doctor decides if and when you need a drug. You need a prescription to get the drug you need. You need to show both your Sparrow PHP ID card and your Medicaid mihealth card when you go to the pharmacy. There are many local pharmacies in the Sparrow PHP network. Please look in your Sparrow PHP Provider Directory for the pharmacy nearest you. Sparrow PHP has a list of covered and non-covered drugs. There are some drugs that your doctor must call Sparrow PHP to get approved before you can get them. 10 phpmichigan.com
Sparrow PHP also covers certain over-the-counter (OTC) medications as long as you have a prescription from your doctor. Please call the Sparrow PHP Customer Service Department at 1-800-661-8299 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 helps your doctor see if you are at risk of early labor. Maternal Infant Health Program (MIHP) Your prenatal care provider may refer you to the Maternal Infant Health Program (MIHP). This is a program that provides a nurse, social worker and nutritionist to help you have a healthy delivery. Your doctor may also refer your newborn. This program helps babies have a healthy first year. All pregnant women are eligible for an assessment. Check with your doctor or call Sparrow PHP Customer Services to learn how to get this service. Women, Infant and Children (WIC) Supplemental Food & Nutrition Program Women, Infants, and Children (WIC) is a government nutrition program. WIC teaches you how to eat healthy and helps by giving you and your children nutritional food. The WIC program is for pregnant women, women who have just had a baby, women who are breast-feeding babies, infants, and children up to 5 years old. If you would like to know more about WIC, call the PHP Customer Service Department. Early, Periodic Screening Diagnosis and Treatment (EPSDT) There is a special program for members under age 21, covered by Medicaid. It is called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). This program provides regular health checkups. Family Planning Services You can get family planning services from your doctor. Family planning is also available at family planning clinics, adolescent health centers or your local health department. You do not need a referral from your PCP to see another provider for family planning. Sexually Transmitted Disease (STDs) 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 is private. You can get care from your PCP, your local health department or a family planning clinic. They are listed in your Sparrow PHP Provider Directory. You do not need a referral from your PCP for these services. 800-661-8299 11
Transportation Services Sparrow PHP can help you with non-emergency transportation. Sparrow PHP provides transportation for covered services only. You can get help with getting a ride if: You do not have a way to get to and from your doctor visit; or You do not have a way to get covered medical items or services. Contact Sparrow PHP s Customer Service Department for help. It is best to let us know 5 days in advance if you need transportation. Please call Sparrow PHP at 1-800-661-8299 as soon as possible if you need to cancel your ride. Members may lose their right to use transportation services if they abuse the service. Some examples are: Letting a non-member use the service. Repeatedly missing the rides. Getting rides for unrelated services. All emergency ambulance services are covered by Sparrow PHP. Care Management Program We want to make sure that you receive quality health care. We will work with your providers to: Make sure we know about all your hospital stays and the services you may receive. Make sure you receive any services you need after you leave the hospital. Make sure you receive care management services if needed. If you have any questions, please call us. How do you make benefit determinations? Sparrow PHP makes decisions about covered health services based on the member s covered benefits, Certificate of Coverage and standard medical practices 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 Sparrow PHP for in advance. We want you to see network doctors and providers. This helps make sure members receive the quality of care and services they deserve. Sparrow PHP does not reward any associates (such as UM, Pharmacy staff or medical directors) for denying services. We also do not allow any kind of incentive program that would award staff for making denial decisions. There is no bonus program for this activity. Sparrow PHP does not track denials or approvals to provide a bonus or incentive to any staff including those who make coverage decisions. Sparrow PHP does not have reward programs with doctors or other providers of care that support under utilization of proper services. Sparrow PHP does have programs in place to alert us of under utilization. If necessary health care services are not delivered this could cause a serious medical problems. Failing to deliver needed services may result in serious or expensive health services later on. Disease Management Sparrow PHP has several disease management programs available to help members manage health conditions. Some of our programs include: Healthy Mom Healthy Baby, Living with Diabetes, and Asthma. Sparrow PHP staff are always striving to help members get needed care, and understand how to stay healthy. You may voluntarily enroll in one of these programs by contacting Customer Service. 12 phpmichigan.com
Case Management Sparrow PHP also has case management services, to help members who may have gaps in care. Case Managers are nurses who work with doctors, members and other treating providers. Working together they eliminate gaps and coordinate care and services. Our case management team is available to assist members with: CSHCS eligibility Chronic, complex health conditions Recent hospitalizations Care needs that aren t being coordinated Over or under utilization New Technology We know that it is important to stay up to date with what is available in health care. Sparrow PHP evaluates new medical technology by: Reviewing research about new technology Reviewing the benefits of using the technology Deciding if it should be included as a benefit Not all health services are covered benefits. The services listed below are examples of excluded services: Any services not medically necessary Elective abortions and related services Elective cosmetic surgery Experimental or investigational drugs, procedures or equipment Services for treatment of infertility YOUR CERTIFICATE OF COVERAGE HAS A FULL LIST OF SERVICES THAT ARE NOT COVERED. SUBSTANCE USE DISORDER SERVICES Substance Use Disorder Services are covered by the State Medicaid program, not by Sparrow PHP. The following resources are available to you. You can call your PCP for help. You can call the Sparrow PHP Customer Service Department for help. You may also call the local agency listed below for your county: Central Diagnostic and Referral Services is responsible for referral and utilization management services for Clinton, Eaton, and Ingham Counties. Contact them at 1-800-342-0349. Mid-South Substance Abuse Center is responsible for referral and utilization services for Ionia County. Contact them at 1-888-230-7629. Access Alliance of Michigan is responsible for referral and utilization services for Shiawassee County. Contact them at 1-800-448-5498. 800-661-8299 13
CUSTOMER SERVICE How can the Sparrow PHP Customer Service Department help me? Sparrow PHP has a Customer Service Department to help you: Answer your questions Change your PCP Connect you with the help you need Assist you with any problems or complaints you have about our services and get back to you with an answer Help you fill out the State Fair Hearing complaint form Obtain this handbook in other formats for members with special needs If I move, who should I call? Your local Department of Human Services (DHS) caseworker. Our Customer Service Department at 1-800-661-8299 or 517-364-8540. It is important for us to be able to reach you with important information. We are happy to help you find a new doctor closer to your house if necessary. What if I get a bill? Sparrow PHP 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. What if I have other health care coverage? If you or other family members have other health insurance coverage through: Your employer Another family member Your auto insurance Worker s Compensation You must call: Your DHS caseworker Sparrow PHP s Customer Service Department Your doctor or provider Anytime your other insurance coverage changes let us know. ENROLLMENT & DISENROLLMENT What do I do if my family size changes? If your family size changes, you will need to: Call your DHS caseworker and; Call the Sparrow PHP Customer Service Department. How do I add my newborn? Newborns are covered by Sparrow PHP from the date of birth. You must notify your DHS caseworker so the newborn child can receive Medicaid. 14 phpmichigan.com
What should I do if I move out of the area? If you move outside of the Sparrow PHP service area, you may no longer have coverage with Sparrow PHP. You must call your DHS caseworker when you move. We will cover all medically necessary health services until you have been disenrolled from Sparrow PHP. Is there any other way I could lose my Sparrow PHP eligibility? 1. You let someone else use your Sparrow PHP ID card for services. 2. You cannot maintain a good relationship with your doctor 3. You are abusive and/or threatening to your doctor and/or Sparrow PHP staff. 4. 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 1-800-661-8299. Please call us at the Customer Service number listed below or on your ID card. Sparrow PHP 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. Important Phone Numbers Sparrow PHP Customer Service Toll Free 800-661-8299 Local 517-364-8540 Transportation Toll Free 800-661-8299 MDCH Medicaid Helpline Toll Free 800-642-3195 Michigan ENROLLS (Enrollment Issues) Toll Free 800-975-7630 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 1-800-649-3777 to reach the Relay Center. The Relay Center will help you call the Sparrow PHP Customer Service Department. AT&T Language Line Service If you have trouble speaking English, you can still call the Sparrow PHP Customer Service Department. We use AT&T Language Line Services. Tell us what language you speak best. We will have an interpreter translate your questions for us. The interpreter will explain the answers to you. Interpretation Services If you speak another language or have trouble understanding your doctor, call the Sparrow PHP Customer Service Department at 1-800-661-8299 for help. 800-661-8299 15
PRIVACY Routine Consent Sparrow PHP members give their routine consent to release personal data including: Last name Address ID number Referrals Claims Sparrow PHP may use this data to: Arrange for your health care Answer agency reviews Gather data for surveys Enroll you in the plan Pay claims Other uses as defined by Sparrow PHP Special Consent Sparrow PHP must have your special consent to release data to others for purposes other than those covered under routine consent. If you cannot give consent, Sparrow PHP will get it from your parent/guardian, Patient Advocate or next of kin. Sparrow PHP 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. Sparrow PHP may share your data with Medicaid as required by the State contract. Anyone who has cause to review your data will sign a statement agreeing to keep it private. Review of the data is in a private place. Anyone contracted or employed by Sparrow PHP who has a need to review your data will make sure your data is secure. Contact us if you would like to review or change your data. If you have questions contact us toll free at 1-800-661-8299. How to contact us if there is a problem If you have a question, concern or complaint, call Sparrow PHP s Customer Service Department at 1-800-661-8299. 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 sometimes you may have a problem or concern that you want us to address. If you have a question, concern or complaint: Call Sparrow PHP s Customer Service Department at the telephone number shown on your Sparrow PHP 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. You must file your appeal within 90 days following an adverse determination notice. 16 phpmichigan.com
Step 1 Write or call Sparrow PHP 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. Reviewers at Sparrow PHP who review appeals are different from the person who made the first decision. Reviewers do not report to anyone who makes decisions about medical care. Medical appeals are reviewed by reviewers who are experts in the condition you are asking about. At any time during the appeal process, you may choose someone to act on your behalf. This may be a doctor. You 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. You may be invited to an Appeal Committee hearing. Sparrow PHP will tell you the date and time of the Appeal Committee hearing. You or your representative may attend in person or by telephone. If you or your representative is 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 Sparrow PHP if you wish to delay the hearing. Otherwise, Sparrow PHP will make a final decision on your appeal after reviewing the information available at the time of the hearing. Sparrow PHP 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 Sparrow PHP s final decision. Step 2 If you are not happy with Sparrow PHP s final decision, you have the right to an external review by the Michigan Department of Insurance and Financial Services (DIFS). You also can work directly with the State of Michigan for the State s Medicaid Fair Hearing process. For information and forms, contact the DIFS Department Director or the Michigan Administrative Hearing System for the Department of Community Health. a) External Review by the Michigan Department of Insurance and Financial Services (DIFS) DIFS Healthcare Appeals Section Office of General Counsel P.O. Box 30220 Lansing MI 48909-7720 Fax: 517-241-4168 Website: www.michigan.gov/difs b) Fair Hearing with the Michigan Administrative Hearing System for Department of Community Health (MAHS for DCH). MAHS for DCH P.O. Box 30763 Lansing, MI 48909 Phone: 517-335-2484 or 877-833-0870 Fax: 517-373-4147 You may have questions about the Fair Hearing process. You may call the Beneficiary Help line (1-800-642-3195) to have a form sent to you. Sparrow PHP Customer Service can help you in filling out and submitting this form. 800-661-8299 17
If your complaint is taken care of before your hearing date you must call 1-877-833-0870 for a Hearing Request Withdrawal Form. The Hearing Request Withdrawal Form is sent to: MAHS for DCH P.O. Box 30763 Lansing, MI 48909 Attn: Hearings/Appeals Sparrow PHP can provide a copy of the DIFS Request for External Review Form and the Administrative Hearing Form. You must send your request for an external review within 60 days from the date you receive Sparrow PHP s decision. You must finish the Sparrow PHP appeal process before asking for an external review by DIFS. You can request a review through the Administrative Hearing System at any time. Sparrow PHP will continue coverage if: a) 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. b) If the appeal involves the termination, suspension, or reduction of a previously authorized course of treatment. c) The services were ordered by an authorized provider. d) The authorization period has not expired. e) You request an extension of benefits. If Sparrow PHP continues or reinstates your benefits while your appeal is pending; we will continue your benefits while your appeal is pending until: a) You cancel the appeal b) You do not request a fair hearing within 10 days from when Sparrow PHP mails an adverse action notice. c) A State Fair Hearing decision does not support your appeal. d) The authorization expires or authorization limits are met. If Sparrow PHP reverses the adverse action decision or the decision is reversed by the State Fair Hearing: we will pay for services provided while the appeal is pending; we will authorize disputed services quickly as your health condition requires. If the denial is upheld, you may be required to pay the cost of the services. PHP Family Care will inform you of our decision in writing. Exceptions for Urgent Situations The above appeal Procedures do not apply if you have a dispute with Sparrow PHP over an upcoming, urgent health service. The doctor needs to notify Sparrow PHP, orally or in writing, to confirm that an urgent situation exists. You or your doctor must file your urgent appeal within 10 days of the adverse determination notice. If your situation is not considered urgent, Sparrow PHP will let you know. The request returns to the standard appeal process. Sparrow PHP will tell you and the doctor the initial decision within 2 (two) days after notification by the doctor. We will put it in writing after speaking with you. 18 phpmichigan.com
You may ask for a review by the Director of DIFS or the Administrative Hearing system at the same time that you go through the Sparrow PHP appeal process. You have 10 days after receipt of Sparrow PHP s decision of your appeal to request a review of the DIFS or the Administrative Hearing System. OTHER INFORMATION 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 description of Advance Directives can be found in your Sparrow PHP 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 30670 Lansing, MI 48909-8170 517 241-2389 or bhpinfo@michigan.gov The BHP Complaint & Allegation website is www.michigan.gov/healthlicense (Click on file a complaint ). For complaints about how your health plan follows your wishes write or call: Department of Insurance and Financial Services Toll free at 877-999-6442 or www.michigan.gov/difs 800-661-8299 19
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: 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 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. You may be referred to a specialist if necessary. You have a right to receive the following: Provider Directory which includes names of providers, hospitals and how to change doctors. (Please call Sparrow PHP Customer Service at 1-800-661-8299 to get a copy or visit our website at 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. This includes information about our preferred drug list. Summary information about the financial arrangements between Sparrow PHP and any provider. This includes how the provider is paid. It also will explain if the payment is based on quality or patient satisfaction. Summary information on Sparrow PHP member satisfaction statistics. Who to Call If you would like any information on Patient Bill of Rights, call the Sparrow PHP Customer Service Department toll free at 1-800-661-8299 HELP US STOP MEMBER FRAUD AND ABUSE Sparrow PHP has 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: Using an expired ID card. A PCP discharging members from their care because of the member s health. Allowing a friend or family member to use your ID card. Changing a prescription. Trying to get a refill that is not allowed on a prescription. Telling a lie to get medical or pharmacy services. Being billed for services when no services were provided. 20 phpmichigan.com
Abuse is when actions are done that are wasteful and cost the health plan or the Medicaid program extra money. Examples of abuse are: Going to the Emergency Room for non-emergency medical services. Hostile or rude behavior in a doctor s office, hospital or pharmacy. Please contact us about any fraud or abuse. You can call us at 517-364-8551, or toll free at 1-800-364-8400 and ask for extension 48551. You can send a letter to: Sparrow PHP P.O. Box 30377 Lansing, Michigan 48909-7877 You can also contact the State of Michigan directly about any fraud or abuse by calling 1-855-MI-FRAUD (643-7283), or by sending a letter to: DCH Office of Health Services Inspector General P.O. Box 30062 Lansing, MI 48909 You don t have to give us your name. We won t tell anybody you called us. 800-661-8299 21
FOR OUR SPARROW PHP MEDICAID MEMBERS Covered Services Sparrow PHP covers the same services that Medicaid does. Coverage is not available unless the service is medically necessary. Coverage is also not available unless the service is provided by or on the referral of your PCP. The services listed below, and the times when they are covered are described in more detail in your Certificate of Coverage (COC). Review your COC to get a better understanding of what services are covered. Covered Services are: Ambulance and other emergency medical transportation Ambulatory (Outpatient) surgery Artificial limbs and orthotics Blood tests for children to check for lead Certified Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Childhood and adult preventative immunizations Chiropractic services Dental services (only for treatment related to an accident) Early periodic screening, diagnosis and treatment services (EPSDT) Emergency services Family planning services Health education and outreach Hearing aids, under 21 years of age Hearing services Home health care services Hospice services Inpatient hospital services Intermittent or short-term restorative or rehabilitative services; up to 45 days in a nursing facility Kidney failure, including dialysis services Laboratory, x-ray, and other diagnostic services Maternity care Medical supplies and equipment Medically necessary weight reduction services Mental health services (up to 20 outpatient visits per year) Out of State services with approval Outpatient hospital services Parenting and birthing classes Physical, Speech and other therapies Physician and other practitioner services Podiatry services Prescription drugs Preventative care and screenings 22 phpmichigan.com
Restorative or rehabilitative services; in a place of service other than a nursing facility Tobacco Cessation services, including drug and support services Transplant services Transportation Treatment for sexually transmitted disease (STD) Vision services Well Child/EPSDT services for persons under 21 Early, Periodic Screening Diagnosis and Treatment (EPSDT) There is a special program for children under age 21, covered by Medicaid. 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: Finding your child s health problems early. If you think your child has a medical problem, talk with your doctor about EPSDT. Providing information about all the special health services available for your children. Keeping your children healthy by giving them the shots they need, when they need them. OB/GYN or Pediatrician Care 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 Sparrow PHP 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 Sparrow PHP pediatrician. If you go to a doctor that is not in the Sparrow PHP Provider Network, you will need a referral from your PCP. Please call the Sparrow PHP Customer Service Department or visit our website if you need help to find a pediatrician. Pediatric Care Care for your children may be received from a pediatrician or any other PCP or certified nurse practitioner. Your children may be seen by a Sparrow PHP network pediatrician for routine/general services without prior authorization or referral. Child and Adolescent Health Center You can also choose to obtain services covered by Sparrow PHP 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. SERVICES NOT COVERED BY SPARROW PHP MEDICAID Sparrow PHP does not pay for the services listed below. Review your COC to get a better understanding of what services are not covered by Sparrow PHP. The State Medicaid program typically covers these services. Please call Customer Service if you need help to find out about these services. We would be happy to get you to the right Medicaid agency that can help you. Dental services. Outpatient partial psychiatric hospital care. Inpatient behavioral health services. 800-661-8299 23
Substance use disorder/detoxification services. Long term basic care or custodial services. Transportation for care and/or services not covered by Sparrow PHP. Mental health not covered by Sparrow PHP after the 20 visits per year. Mental health services for enrollees who meet the serious mental illness or severe emotional disturbance guidelines under Medicaid policy. Home and Community based waiver program services. Traumatic Brain Injury Program Services. Some school services billed by Intermediate School Districts. Personal care or home help services. Some developmental disability care. Intermittent or short-term restorative or rehabilitative services after 45 days in a nursing facility. Maternal Infant Health Program (MIHP) What happens if I lose my Medicaid eligibility? If you lose your State Medicaid eligibility, you will be disenrolled from Sparrow PHP. However, if you become eligible for Medicaid in less than 2 full months after the date of your disenrollment, you will be automatically enrolled in Sparrow PHP again. You do not have to do anything to be re-enrolled. If you lose your Medicaid eligibility and then are eligible again after 2 full months you will be asked again to pick a managed care plan. You may pick Sparrow PHP again at that time. If you lose your Medicaid eligibility permanently, you will no longer be eligible for health care coverage with Sparrow PHP. 24 phpmichigan.com
FOR OUR CHILDREN WITH SPECIAL HEALTH CARE SERVICES (CSHCS) MEMBERS 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 Medical Health Plan Enrollees with Children s Special Health Care Services 1. Help from your Local Health Department with: Community resources schools, community mental health, financial support, childcare, Early On, and the Women Infants and Children (WIC) program Transitioning to adulthood Orthodontia Only for specific CSHCS qualifying diagnosis, such as Cleft Palate/Cleft lip Medically necessary, related to condition Not for cosmetic purposes Respite 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 CSHCS Family Phone Line a toll-free phone number (800-359-3722) available Monday through Friday from 8:30 a.m. to 5:30 p.m. Parent-to-parent support network Parent/Professional training programs Financial help to go to conferences about CSHCS medical conditions and Relatively Speaking, a conference for siblings of children with special needs. 3. Help from the Children s Special Needs (CSN) Fund The CSH Fund helps CSHCS families get items not covered by Medicaid or CSHCS. To see if you qualify for help from the CSN Fund, call 517-241-7420. Examples include: Wheelchair ramps Van lifts and tie downs Therapeutic tricycles Air Conditioners Adaptive recreational equipment Electrical service upgrades for eligible equipment 800-661-8299 25
SERVICES COVERED BY SPARROW PHP CSHCS Sparrow PHP covers the same services that Medicaid does. Coverage is not available unless the service is medically necessary. Coverage is also not available unless the service is provided by or on the referral of your PCP 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: Ambulance and other emergency medical transportation Ambulatory (Outpatient) surgery Artificial limbs and orthotics Blood tests for children to check for lead Certified Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Childhood and adult preventative immunizations Chiropractic services Dental services (only for treatment related to an accident) Early periodic screening, diagnosis and treatment services (EPSDT) Emergency services Family planning services Health education and outreach Hearing aids, under 21 years of age Hearing services Home health care services Hospice services Inpatient hospital services Intermittent or short-term restorative or rehabilitative services; up to 45 days in a nursing facility Kidney failure, including dialysis services Laboratory, x-ray, and other diagnostic services Maternity care Medical supplies and equipment Medically necessary weight reduction services Mental health services (up to 20 outpatient visits per year) Out of State services with approval Outpatient hospital services Parenting and birthing classes Physical, Speech and other therapies Physician and other practitioner services Podiatry services Prescription drugs Preventative care and screenings Restorative or rehabilitative services; in a place of service other than a nursing facility 26 phpmichigan.com
Tobacco Cessation services, including drug and support services Transplant services Transportation Treatment for sexually transmitted disease (STD) Vision services Well Child/EPSDT services for persons under 21 OTHER INFORMATION ABOUT SPARROW PHP CSHCS SERVICES Information about OB/GYN and Pediatrician Services A referral from a PCP is not required 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 Sparrow PHP Provider Network. Please call our Customer Service Department or visit our website if you need help in finding an OB/GYN doctor. Pediatric Care Care for your children may be received from a pediatrician or any other PCP or certified nurse practitioner. Your children may be seen by a Sparrow PHP network pediatrician for routine/general services without prior authorization or referral. Your PCP may also be your specialist if able to handle your CSHCS diagnosis. If you go to a doctor that is not in the Sparrow PHP Provider Network, you will need a referral from your PCP. Please call the Sparrow PHP Customer Service Department or visit our website if you need help to find a pediatrician or other provider. Early, Periodic Screening Diagnosis and Treatment (EPSDT) There is a special program for children under age 21, covered by Medicaid. 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: Finding your child s health problems early. If you think your child has a medical problem, talk with your doctor about EPSDT. Providing information about all the special health services available for your children. Keeping your children healthy by giving them the shots they need, when they need them Child and Adolescent Health Center You can also choose to obtain services covered by Sparrow PHP 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. 800-661-8299 27
SERVICES NOT COVERED BY SPARROW PHP CSHCS Sparrow PHP does not pay for the services listed below. Review your COC to get a better understanding of what services are not covered by Sparrow PHP. The State Medicaid program or the Children Special Needs Fund typically covers these services. Please call Customer Service if you need help to find out about these services. We would be happy to get you to the right Medicaid agency that can help you. Dental services. Outpatient partial psychiatric hospital care. Inpatient behavioral health services. Substance use disorder/detoxification services. Long term basic care or custodial services. Transportation for care and/or services not covered by Sparrow PHP. Mental health not covered by Sparrow PHP after the 20 visits per year. Mental health services for enrollees who meet the serious mental illness or severe emotional disturbance guidelines under Medicaid policy. Home and Community based waiver program services. Traumatic Brain Injury Program Services. Some school services billed by Intermediate School Districts. Personal care or home help services. Some developmental disability care. Intermittent or short-term restorative or rehabilitative services after 45 days in a nursing facility. Maternal Infant Health Program (MIHP) What Happens with Loss of Medicaid Eligibility? If you lose your State Medicaid eligibility, you will be disenrolled from Sparrow PHP. However, if you become eligible for Medicaid in less than 2 full months after the date of your disenrollment, you will be automatically enrolled in Sparrow PHP again. You do not have to do anything to be re-enrolled. If you lose your Medicaid eligibility and then are eligible again after 2 full months you will be asked again to pick a managed care plan. You may pick Sparrow PHP again at that time. If you lose your Medicaid eligibility permanently, you will no longer be eligible for health care coverage with Sparrow PHP. 28 phpmichigan.com
FOR OUR Sparrow PHP HEALTHY MICHIGAN PLAN (HMP) MEMBERS Services Covered Sparrow PHP HMP covers the following services. Coverage is not available unless the service is medically necessary. Coverage is also not available unless the service is provided by or on the referral of your PCP. 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: Ambulance and other emergency medical transportation Ambulatory (Outpatient) surgery Artificial limbs and orthotics Certified Nurse Midwife services Certified Family Nurse Practitioner services Preventative immunizations Chiropractic services Dental services Early periodic screening, diagnosis and treatment services (EPSDT) to age 21. Emergency services Family planning services Health education and outreach Hearing aids Hearing services Home health care services Hospice services Inpatient hospital services Intermittent or short-term restorative or rehabilitative services; up to 45 days in a nursing facility Kidney failure, including dialysis services Laboratory, x-ray, and other diagnostic services Maternity care Medical supplies and equipment Medically necessary weight reduction services Mental health services (up to 20 outpatient visits per year) Oral Surgery Out of State services with approval Outpatient hospital services Parenting and birthing classes Physical, Speech and other therapies Physician and other practitioner services Podiatry services Prescription drugs Preventative care and screenings Rehabilitative and habilitative services and devices 800-661-8299 29
Tobacco Cessation services, including drug and support services Transplant services Transportation Treatment for sexually transmitted disease (STD) Vision services Additional Information about HMP Services If you think you may be pregnant, see your doctor as early as possible. If you find that you are pregnant while in the Healthy Michigan Plan, the plan will cover medical services while you are pregnant and after your baby is born. Pregnant women may choose to receive medical services through the Medicaid program; to do so, contact your Department of Human Services specialist to report your pregnancy and due date. A referral from a PCP is not required 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 Sparrow PHP Provider Network. Please call our Customer Service Department or visit our website if you need help in finding an OB/GYN doctor. Cost Share for Coverage and Co-Pays for Services The Healthy Michigan Plan requires those with annual incomes between 100% and 133% of the federal poverty level to participate in health care cost sharing. Your cost sharing will be based on 2% of your annual income. It cannot exceed 5% if your income. The Health Michigan Plan has co-pays.. Co-pay amounts are listed below. Co-pays will not be collected for the first 6 months after enrollment. For more information about co-pays please check Sparrow PHP at our website phpmichigan.com or go to healthymichigan.org. You may also discuss your co-pays at your doctor visits. You can reduce your annual contribution and co-pays by participating with Sparrow PHP in healthy behavior activities: Completing an annual health risk assessment Changing unhealthy behavior activities Seeing your doctor for preventive health care. Watch for letters from us to inform you on ways to reduce your annual contributions and co-pays. As a Sparrow PHP HMP member you will pay your cost sharing through a special health care account called the MI Health Account.. The MI Health Account helps you keep track of your healthcare costs. The Healthy Michigan Plan MI Health Account Statement will tell you what you have to pay and how to pay it. You will be able to pay it online and by mail. Online, you will go to healthymichigan.org and click Make MI Health Account Payment. You can pay using your bank account information (no credit cards). 30 phpmichigan.com
Healthy Michigan Plan co-pays: Covered Service Co-Pay Physician Office Visits (including Free-Standing Urgent Care Centers) $2 Outpatient Hospital Clinic Visit $1 Emergency Room Visit for Non-Emergency $8 Services Co-pay only applies to non-emergency service There is no co-pay for true emergency services Inpatient Hospital Stay (with the exception of $50 emergency admissons Pharmacy $1 generic $3 brand Chiropractic Visits $1 Dental Visits $3 Hearing Aids $3/aid Podiatric Visits $2 Vision Visits $2 SERVICES NOT COVERED BY SPARROW PHP HMP Sparrow PHP HMP does not pay for the services listed below. Review your COC to get a better understanding of what services are not covered by Sparrow PHP HMP. The State Medicaid program typically covers these services. Please call Customer Service if you need help to find out about these services. We would be happy to get you to the right Medicaid agency that can help you. Outpatient partial psychiatric hospital care. Inpatient behavioral health services. Substance use disorder/detoxification services. Long term basic care or custodial services. Transportation for care and/or services not covered by Sparrow PHP HMP. Mental health not covered by Sparrow PHP HMP after the 20 visits per year. Mental health services for enrollees who meet the serious mental illness or severe emotional disturbance guidelines under Medicaid policy. Home and Community based waiver program services. Traumatic Brain Injury Program Services. Some school services billed by Intermediate School Districts. Personal care or home help services. Some developmental disability care. 800-661-8299 31
Intermittent or short-term restorative or rehabilitative services after 45 days in a nursing facility. Maternal Infant Health Program (MIHP) What Happens if I Lose my Medicaid Eligibility? If you lose your State Medicaid eligibility, you will be disenrolled from Sparrow PHP HMP. However, if you become eligible for Medicaid in less than 2 full months after the date of your disenrollment, you will be automatically enrolled in Sparrow PHP again. You do not have to do anything to be re-enrolled. If you lose your Medicaid eligibility and then are eligible again after 2 full months you will be asked again to pick a managed care plan. You may pick Sparrow PHP again at that time. If you lose your Medicaid eligibility permanently, you will no longer be eligible for health care coverage with Sparrow PHP. Revised: Jan. 2015 32 phpmichigan.com
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www.phpmichigan.com 517-364 - 8540 1-800-661-8299 Sparrow PHP 1400 E Michigan Ave Lansing, MI 48912 An affiliate of sparrow hospital Rev 04/15