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NLDICAID PLAN

2012 - 2013 HealthPlus Partners


Member Handbook
This packet includes your:
n Subscriber Contract
n Beneft Summary
n Transportation Pocket Card
HealthPlus Partners ID Card
If you are a new HealthPlus Partners member, you should have already received your member ID card.
You will only get this card once, not every month. If you do not receive your card within the next few
days, please call Customer Service toll free at 1-800-332-9161, TDD line for the deaf toll free at 1-800-
992-5070.
Once your card arrives, please make sure the information is correct. If not, please call Customer Service.
Keep your card in a safe place. When you go to your doctors ofce, or to the pharmacy, show your
HealthPlus Partners card and your green mihealth card.
If you have questions about your card, your benefts or how to access care, please call Customer
Service.
Provider Directory
If you would like a provider directory, please call Customer Service toll-free at 1-800-332-9161, TDD line
for the deaf toll-free at 1-800-992-5070. You can also visit our website to do a provider search online at
www.healthplus.org.
HealthPlus Partners Transportation
Call our transportation line if you are in need of transportation to your medical appointments.
HealthPlus provides transportation to and from any services covered by HealthPlus Partners including
your re-determination visit with your caseworker if needed. A wallet size transportation card is
included in this packet in the front of the book for your use. You may call to schedule transportation
services anytime 24 hours 7 days a week including weekends and holidays toll free at 1-888-676-1783.
HealthPlus Partners has many member incentives designed to keep you healthy that you will hear
about throughout the year. Some of those include incentives to help you stop smoking and for other
services such as Well Child visits and Prenatal care. Our website also contains lots of tools to help you
stay healthy. Simply go to www.healthplus.org and check out our various programs.
Welcome to HealthPlus Partners where Our Vision is a Healthier Community!
Welcome!
Thank you for choosing
HealthPlus Partners.
Introduction
Welcome to HealthPlus Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
View us online at www.healthplus.org . . . . . . . . . . . . . . . . . . . . . . 2
Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Your mihealth Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Your HealthPlus Partners Identifcation Card . . . . . . . . . . . . . . . . 2
Choosing the Right Primary Care Physician (PCP) . . . . . . . . . . . 3
Specialists as a PCP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
How to Choose or Change Your Doctor . . . . . . . . . . . . . . . . . . . . . 4
Enrolling New Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
How to Use the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Canceling and Changing Appointments . . . . . . . . . . . . . . . . . . . . 4
Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Leaving HealthPlus Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Your Health Benefts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Services Not Covered by HealthPlus Partners . . . . . . . . . . . . . . . 6
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Out of Network Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Copays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
How to Access Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Pharmacy Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Prescription Copay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Prior Authorization/Step Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Mandatory Specialty Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . 8
Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Low Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Family Planning Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Language Interpretation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Member Materials in Other Formats . . . . . . . . . . . . . . . . . . . . . . . . . 9
Utilization Case Management Program . . . . . . . . . . . . . . . . . . . . . 9
Care Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Foster Care Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Transportation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Make the Most of Your Health Benefts . . . . . . . . . . . . . . . . . . . . .10
Childrens Special Health Care Services (CSHCS)
How to Enroll in CSHCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Your HealthPlus Partners ID Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Your CSHCS Health Benefts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Additional Benefts for CSHCS Health Plan Members . . . . . . .13
Services Not Covered by HealthPlus Partners but
Covered by the State Medicaid Program . . . . . . . . . . . . . . . . 13
Services Not Covered by HealthPlus Partners or
Covered by the State Medicaid Program . . . . . . . . . . . . . . . . 13
Medicare/Medicaid Members
Your HealthPlus Partners ID Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Choosing the Right Primary Care Physician. . . . . . . . . . . . . . . . . 14
Your Medicare/Medicaid Health Benefts . . . . . . . . . . . . . . . . . . . 15
Turning 65? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Part B Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Part D Drug Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Womens Health
Janets Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
OB/GYN Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Having a Baby? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Childbirth Education Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Maternal Infant Health Program (MIHP) . . . . . . . . . . . . . . . . . . . . 17
Post-Partum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Women, Infants and Children (WIC)
Supplemental Food & Nutrition Program . . . . . . . . . . . . . . . 18
Get Tested for Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Dont Forget Your Pap Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
How to Detect Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Childrens Health
Well Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Lead Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Immunizations (Shots) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Colds and Sore Throats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Mens Health
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Health and Wellness
Health and Wellness Information . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Health and Wellness Online. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Stop Smoking Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Weight Management Programs and Services . . . . . . . . . . . . . .20
Health and Wellness Self-Help Information . . . . . . . . . . . . . . . . .20
HealthQuest Toll Free Health Information Line . . . . . . . . . . . . .20
Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
HealthQuest Perks Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Disease Management
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Miscellaneous
New Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
If You Have Other Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
If You Receive a Bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
If You Move or Lose Medicaid Eligibility . . . . . . . . . . . . . . . . . . . . .23
Request for Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Member Satisfaction Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
There are Two Stages of Grievances . . . . . . . . . . . . . . . . . . . . . . . .24
State Fair Hearing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . .25
Patient Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Medical Decisions/Advanced Directives . . . . . . . . . . . . . . . . . . . .27
Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Explanation of Benefts (EOB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
HealthPlus Partners Subscriber Contract. . . . . . . . . . . . . . . . . . . .29
HealthPlus Partners Board of Directors . . . . . . . . . . .Back Cover
Other Important Phone Numbers . . . . . . . . . . . . . . . .Back Cover
HealthPlus Partners Service Area . . . . . . . . . . . . . . . . .Back Cover
Page 1 Table of Contents
Table of Contents
n Lost or stolen ID cards
n If you receive a bill
n Quality of treatment concerns
n Questions about the program
n If you have special needs and/or
need written materials in alternative
formats
n If you need interpreter services
Other numbers:
n Outside of Michigan 1-800-462-7060
(toll free)
n Telecommunications Device for the
Deaf (TDD) 1-800-992-5070 (toll free)
If you would like to write or visit us, our
addresses are:
2050 South Linden Rd.
Flint, MI 48532
5454 Hampton Place
Saginaw, MI 48604
Introduction
Welcome to HealthPlus Partners!
W
e are pleased to have you as a member of HealthPlus Partners. We
are a Medicaid health plan. We have doctors and other providers
to give you the services you need. HealthPlus Partners ofers
members a wide range of health care benefts.
HealthPlus of Michigan became a corporation in 1977. HealthPlus Partners
became a wholly-owned subsidiary corporation of HealthPlus of Michigan
in 2003. We are a non-proft company. We are licensed by the State of
Michigan. The federal government has qualifed us as a health maintenance
organization. We want to help you make the most of your health care
benefts. We believe in quality care. Welcome to HealthPlus Partners!
How to Use this Book
HealthPlus Partners covers multiple
Medicaid members. Everything in this
book applies to all members except for the
sections specifcally identifying benefts
for key groups. We hope this helps provide
clarity for the benefts of each group. If
you have questions, please call customer
service toll free at 1-800-332-9161.
View us online at
www.healthplus.org
Check us out on our website. The site tells
you about our doctors, programs and
services. You can also fnd out about your
rights and responsibilities as a HealthPlus
Partners member. The site has a map
of our service area. It also provides lots
of useful consumer health information.
There is a link to the National Committee
for Quality Assurance (NCQA). NCQA is
an independent company that checks
managed care plans across the country to
improve the quality of care.
Customer Service
We want to help you make the most
of your benefts. If any of the following
should happen, call Customer Service
(24 hours a day, 7 days a week) toll free at
1-800-332-9161.
n Address changes
n PCP change
n Other health treatment coverage
Page 2 Introduction
You must also report changes to the
State of Michigan. This can be done by
contacting your case worker.
Your mihealth Card
The State of Michigan issues each
Medicaid, Medicaid Childrens Special
Health Care Services (CSHCS) or Medicaid/
Medicare benefciary a permanent
Medicaid ID card called a mihealth card.
Your mihealth card provides the following
information:
1. Benefciary ID number
2. Benefciary name
This card is to be used for services not
covered by HealthPlus Partners as listed on
page 6 of this handbook. You should also
show this card with your HealthPlus
Partners ID card when you receive services.
If this card is lost or stolen, please call the
State of Michigan Benefciary helpline at
1-800-642-3195.
Your HealthPlus Partners
Identifcation Card
Your identifcation card lists you as a
member who is covered by HealthPlus
Partners. If any information on the card is
incorrect, please call Customer Service (24
hours a day, 7 days a week) at
1-800-332-9161 or visit us at
www.healthplus.org with the correct
information as soon as possible.
Each member will get a HealthPlus
12345678 (Your ID Number)
JOHN DOE (Your Name)
1.
2.
STATE OF
MICHIGAN
MEDICAID
CARD
1.
2.
Page 3 Introduction
Partners card and a green mihealth (My
Health) card from the State. You will need
both cards to get services. If you lose
your HealthPlus Partners card, or if the
information changes, call us toll free at
1-800-332-9161.
Your HealthPlus Partners card provides the
following information:
1. Group Number
Indicates group or individual coverage
2. Coverage
Identifes your beneft level
3. Efective Date
The date your current coverage became
efective
4. Recipient ID Number
Member identifcation number
5. Member Name
Member name
6. Primary Care Physician (PCP) Name
Name of members PCP
7. PCP Telephone
PCP ofce telephone number
8. Hospital
Hospital your doctor uses and where
you will be sent, if needed
Always show both of your cards when you
receive care. Do not allow anyone else to
use your identifcation card. Improper use
of your card is considered fraud and can
result in the cancellation of your health
care coverage with HealthPlus Partners.
If you lose your identifcation card, or
require additional cards, please contact
Customer Service or visit us on the Web at
www.healthplus.org.
Your identifcation card is also important
if you are hospitalized. Please notify
HealthPlus Partners in the event that a
hospitalization occurs. The back of your
card has the telephone number to call.
Always have your card handy when you
call or visit HealthPlus Partners. This helps
us serve you quickly and efciently.
Choosing the Right Primary
Care Physician (PCP)
You must choose a HealthPlus Partners
Primary Care Physician (PCP) as your main
doctor. When choosing a doctor, think
about what is important to you and your
family. You may want to choose a doctor
close to your home or your childrens
school. You may choose a doctor in family
practice, internal medicine, a pediatrician
for your child or a doctor at a clinic. If
you choose a pediatrician as your childs
PCP, you do not need a referral for these
services. All of these doctors provide
primary care, but in diferent ways.
Family Practice doctors give health care
to male and female patients of all ages and
health problems. They can also be your
childs pediatrician. Some deliver babies
and take care of womens health needs.
Internists give care to adults with both
regular health care needs and special
problems.
Pediatricians take care of babies, children
and teenagers.
Federally Qualifed Health Centers
(FQHCs) give care to male and female
patients of all ages and health problems.
They also provide other services not
covered by HealthPlus Partners, but are
covered by the State such as dental care.
You may go to any FQHC in any county
without a referral from your PCP. You may
also choose to get your services from one
of the FQHCs listed below by choosing
them as your PCP:
n Hamilton Family Health Center
(Genesee County)
n Health Delivery Inc.
(Saginaw, Bay, and Shiawassee
Counties)
Clinics are stafed with resident doctors
who must spend an extra three to fve
years in training for their specialty. Board
certifed doctors supervise them. When
you choose a clinic as your doctor, you
will see any of the resident doctors seeing
patients on that day.
You also may choose to get care from
Child and Adolescent Health Centers
without prior authorization.
GENESEE COUNTY
n Mott Childrens Health Center-
Northwestern HS
n Mott Childrens Health Center-
Beecher/Dolan MS
n Mott Childrens Health Center
SAGINAW COUNTY
n Saginaw CHD-Bridgeport/Spaulding
and Thurston MS
n Saginaw CHD-Ricker MS
n Health Delivery, Inc-Saginaw HS
n Health Delivery, Inc-Arthur Hill HS
SHIAWASSEE COUNTY
n Shiawassee County Health
Department-Durand MS/HS
When you pick your doctor, you agree to
use the same specialists and hospital your
doctor uses. It is important to have a good
relationship with your doctor so he or she
knows about your health.
NLDICAID PLAN
RXBIN 610011 RXPCN 23050
RECIPIENT NUMBER
1234567890
RECIPIENT NAME
JOHN DOE
PCP NAME/TELEPHONE#
DR. SMITH
Hometown Regional Medical Center
EFFECTIVE DATE
OF COVERAGE
01/01/11
GROUP
#987654
(810) 750-6060
Aproduct of HealthPlus of Michigan, Inc.
BP = 2.

3.
1.
7.
4.
5.
6.
8.
You may change your PCP for any reason.
The change will be efective on the frst
day of the month after you make your
request. A customer service representative
can answer any questions you may
have about the doctor you choose or any
doctor you will see. If you want to know if a
doctor is male or female, where they went
to medical school, or if you have any other
questions, call 1-800-332-9161.
Local Health Departments are also
available to provide some health care
services. If available in your county, you
may receive primary care from these
locations without prior authorization.
Specialists as a PCP
Specialists are doctors who focus on
one area of medicine or one part of the
body. Some people have chronic health
conditions and need to see a specialist a
lot. In such cases, it may be better for the
specialist to be your main doctor and act
as your PCP. If this occurs, our medical staf
will make that decision with you.
How to Choose or Change
Your Doctor
The provider directory gives you the
names, locations and specialties of doctors
who are taking new patients in your
county. If you do not choose a doctor, one
will be chosen for you.
When you pick your doctor, you agree to use
the same hospital that your doctor uses. The
accepting statusof each doctor is listed
after the hospital they use. The accepting
status for HealthPlus Partners doctors is
listed below:
Yes means you can choose this doctor.
Conversions mean you can choose this
doctor if you are already a patient of this
doctor when you get HealthPlus Partners.
Families Only means you can choose this
doctor if everyone in your family does.
Newborns Only means you can choose
this doctor for your baby if your baby is
one year old or younger. If your other kids
already see this doctor, and they now have
HealthPlus Partners, they can stay with this
doctor.
Over 50 means you have to be 50 years
old or older to choose this doctor.
Over 65 means you have to be 65 years
old or older to choose this doctor.
No means you cannot choose this doctor.
You may view the provider directory
online at www.healthplus.org. If you
would like a printed copy of the provider
directory, please call Customer Service.
You can change doctors at any time. The
change will be efective on the frst day of
the month after you make your request. If
you have any questions about choosing a
doctor, or the doctor youve been given,
please call Customer Service.
Enrolling New Dependents
If someone new is added to your case,
you must call Michigan ENROLLS at
1-888-ENROLLS to choose HealthPlus
Partners as your health plan. If you have a
baby, the baby will automatically become
our member. Please call us with the name
of your new baby and his or her new ID
number as soon as you receive it.
Medicaid Eligibility
Re-Determination
On an annual basis, Medicaid enrollees
must go through an eligibility re-
determination. This process is done by the
State through your caseworker and looks
to see if you still qualify for Medicaid. The
State will send you notice of this time with
any needed paperwork. It is important
that you complete them and turn them in
to your caseworker. This will help to keep
your Medicaid benefts and HealthPlus as
your health insurance plan.
How to Use the Plan
You will get most of your services from
your PCP. If needed, your PCP will refer
you to a specialist. Your PCP will set up all
of your health services including hospital
stays. If you get services without your PCPs
okay, you may have to pay for the service.
If you need to see your PCP, call for an
appointment. The number is on your ID
card. Describe why you need to see the
doctor. The doctors assistant may give
you an appointment. He or she may also
suggest that you try something at home
or go to another doctor. Be ready for your
appointment.
n Write down how you are feeling.
n Write down questions you want to
ask.
n Write down the names of the
medicines you are taking.
n Ask questions about your doctors
directions.
Canceling and Changing
Appointments
If you need to change or cancel your
appointment, please call your doctor the
day before. Many doctors will discharge
you as their patient for multiple no show
appointments.
No shows are appointments you do not
keep and do not notify the doctor prior
to your appointment that you will not be
there. Calling ahead of time allows your
doctor to see someone else who may
need services.
Referrals
Your PCP is responsible for your health
care. Your PCP will decide if you need
to see a specialist. If you are referred
to a specialist, you will get a copy of the
referral. The referral will tell you how many
visits you get and what services you will
have. If you run out of visits, call your PCP.
Restrictions
You may not be able to go to some
doctors. Most doctors refer their patients
to specialists who are part of their health
system. In most cases, your PCP will tell
you which doctors you may see.
There are some services that need
approval by HealthPlus Partners before
you can receive the service. When
approval is required, your doctor and/or a
case manager will coordinate the process.
Introduction
Page 4 Introduction
Here are your benefts: Here is how to use them:
Primary Care Services
Ofce visits
Well child visits (includes the developmental/behavioral health
Baby shots
Lab and X-rays
Specialist services okayed by your PCP
Medically necessary weight loss services
End Stage Renal Disease
Maternity care
Pre and post-natal services
Certifed nurse midwife services
Call your PCP for an appointment
Your PCP will arrange for your care
Go to your PCP or any in-plan OB/GYN
Inpatient Hospital Services
Semi-private room Doctor Surgery care Maternity care
Diagnostic care Lab and X-ray Drugs and supplies
Organ and tissue transplants
Your PCP will arrange for your care
Outpatient Hospital Services
Lab and X-rays Outpatient surgery Diagnostic testing
Your PCP will arrange for your care
Emergency Care
Medical care Ambulance
Go to nearest emergency room or call 911
Urgent Care After Hours Call your PCP and/or go to an After Hours Clinic
Pharmacy Services
Prescription drugs Some over-the-counter items
Family Planning Services
Exam
Birth control
Sterilization (must be 21 years old)
See Subscriber Contract for limitations
Infertility screening and diagnosis
Screening and treatment for sexually transmitted diseases (STD)
Go to your PCP or a Family Planning provider
Your PCP will arrange for your care
Hearing and Speech
Diagnostic services
Hearing aids covered for members under the age of 21
Hearing aid batteries
Your Doctor will arrange for your care
Mental Health Services
Twenty visits each year
Members can choose any participating counselor, but may want to
ask their PCP or HealthPlus Partners at 1-800-555-5025 for help in
selecting a counselor.
Vision
One eye exam every two years
Glasses every two years
Replacement glasses
Diabetic eye exam and glaucoma screening
Call your HPP vision provider to arrange for routine eye care.
Medical Equipment
Medical supplies Durable Medical Equipment
Prosthetics and orthotics
Your Doctor will arrange for your care
Other Services
Home health care Chiropractic services Podiatrist services Oral surgery and related services Allergy testing and treatment
Short-term outpatient rehabilitative therapy (physical, occupational, speech and language)
Short-term restorative or rehabilitative services in nursing facility Blood lead screening, treatment and follow up
Health education Parenting and childbirth classes Certifed pediatric and nurse practitioner services
Out-of-state services Hospice services Midwife services Treatment for communicable diseases
Your PCP will arrange for your care when needed
assessment
Your Health Benefts
A brief summary of your benefts are listed
on this page. You must see your PCP or be
referred for care except as otherwise stated
in this handbook. Please refer to your
Subscriber Contract for a more detailed
description of your benefts.
Remember, all services provided by
non-participating doctors (except
for medical emergencies) should be
okayed by your PCP unless stated. You
may have to pay for services that are not
okayed by your PCP. All authorized and
covered services provided by HealthPlus
are covered in full. There are no copays
for these services.
Page 5 Your Health Benefts
Your Health Benefts
Page 6 Your Health Benefts
Leaving HealthPlus
Partners?
You receive a lot of information from the
Department of Human Services about
your health care benefts. Its a lot of
information that can be confusing. Each
month, we receive an enrollment fle from
the State that tells us those members that
are being termed from our plan at the
end of the month. We only have one week
between the time we fnd out and the
end of the month.. HealthPlus will work
to notify you if we have been told by the
State that your enrollment is ending. If this
happens for you, please:
n Call your caseworker immediately, or
n Call MIBridges at 1-888-642-7434, or
n Go online at https://www.mibridges.
michigan.gov/access
This will tell you what is happening with
your case. We hope you will choose
HealthPlus Partners as your health plan
again.
Services Not Covered by
HealthPlus Partners
Services Not Covered by HealthPlus
Partners But Covered by the State
Medicaid Program
We do not pay for these services. We
would be happy to help you contact the
right agency.
1. Long-term basic care services
Contact HealthPlus Partners case
management for assistance
2. Substance abuse services
Contact your local coordinating
agency
3. Inpatient mental health services
Contact your local community mental
health agency
4. Routine dental care
See any dental provider who accepts
Medicaid
5. Transportation for care or services
not covered by HealthPlus Partners
Contact your case worker
6. Mental health after 20 outpatient
visits
Contact your local community mental
health agency
7. Outpatient partial psychiatric
hospital care
Contact your local community mental
health agency
8. Personal care or home help services
Contact your case worker
9. Some school services billed by
intermediate school districts
Contact your local school district
10. Some developmental disability care
Contact your local community mental
health agency
11. Home and community-based waiver
services
Contact your case worker
12. Intermittent or short-term
restorative or rehabilitative services
(in a nursing facility), after 45 days
Contact the State Benefciary Help Line
13. Traumatic brain injury program
services
Contact the State Benefciary Help Line
14. Substance abuse medications,
antipsychotic medications
and other behavioral health
medications, medications for HIV/
AIDS, medications to treat bleeding
disorders and some rare metabolic
conditions.
15. Maternal Infant Health Program
(MIHP) Services
Contact your local MIHP provider or
HPP for assistance in locating one near
you.
These are covered by the State of Michigan
through your mihealth card.
Services Not Covered by HealthPlus
Partners or by the State Medicaid
Program
We do not pay for these services nor does
the State Medicaid Program. You will have
to pay for these services:
1. Elective abortions and related
services (covered only if given to
save the life of the mother or to end
a pregnancy resulting from rape or
incest)
2. Acupuncture
3. Experimental/investigational drug
procedures or equipment
4. Elective cosmetic surgery
5. Any services not medically necessary
6. Treatment for infertility
Please refer to your Subscriber Contract
for details of covered and non-covered
services.
Urgent Care
In the HealthPlus Partners Service
Area
You dont have to use the emergency
room when you are sick and your doctors
ofce is closed. We have many after hours
clinics that will help you. If you cannot wait
until the next day to see your doctor, call
his or her telephone number to reach the
answering service or doctor on call. They
will tell you which after hours clinic to use.
If you get urgent care services from an out
of network provider without authorization,
you may have to pay the bill.
Outside of the HealthPlus Partners
Service Area
If you are outside of the HealthPlus
Partners service area and you are sick,
please call your doctors telephone
number. He or she will help you decide
what to do.
Examples of some types of urgent
problems are:
n Sore throat
n Ear infection
n Low-grade fever
n Skin rash
n Cough
n Headache
n Flu or colds
n Minor cuts
If you get non-emergency services outside
the service area without authorization, you
will have a copay and you may have to pay
the bill.
Emergency Care
In or outside of the HealthPlus
Partners Service Area
Call your PCP if you are sick. If the ofce is
closed, you can reach your doctor through
the answering service at his or her ofce
Page 7 Your Health Benefts
number. If it is an emergency, they will
contact your doctor.
If you have a life-threatening condition,
go to the nearest emergency room or call
911.
If you are in a life-threatening emergency,
911 will provide emergency transportation
for you. If you are admitted to the hospital,
have someone call HealthPlus Partners
as soon as possible. The number is on the
back of your HealthPlus Partners ID card.
This will help us arrange to pay for any
service.
Do not use the emergency room or after
hours center for illness that can be treated
by your doctor during ofce hours.
Remember, if you go to the emergency
room for a non-emergency service, you
may have to pay the bill.
Examples of some types of emergencies are:
n Heart attack
n Chest pain
n Stroke
n Broken bones
n Knife wound
n Gunshot wound
n Severe breathing problems
n Severe bleeding
n Convulsions
n Unconsciousness
n Burns
n Poisoning
n Accidents
n Fainting or severe dizziness
n A woman in labor
n Damage to your eyes like getting
bleach or objects in your eyes, or
being hit in the eye with something.
Out of Network Services
HealthPlus Partners has a large provider
network covering all specialty areas.
However, there may be times when the
services you need are not available within
our network. If this happens, your PCP will
refer you to a hospital or provider that can
address your medical needs. HealthPlus
Partners will pay for covered services
referred by your PCP. If you do not have a
referral, you may have to pay the bill.
HealthPlus Partners covers services at your
doctors hospital. If you need emergency
treatment and cant get to your doctors
hospital, please go to the nearest
emergency room. HealthPlus Partners will
pay for the visit.
Copays
All authorized and covered services
provided by HealthPlus are covered in full.
Attention Dual Eligibles (Medicare/
Medicaid) Members
HealthPlus Partners does not cover Part D
drugs. These are covered by your Part D
plan. If you do not have one, you will be
responsible for those drugs. HealthPlus
has suggestions on ways to reduce the
cost of these drugs if you do not have a
Part D plan. Call our Customer Service.
Behavioral Health Services
If youre depressed or need counseling to
get through a difcult time, you can get
help. For behavioral health services you
can choose any participating counselor,
but you may want to ask your PCP or
HealthPlus Partners toll free at 1-800-555-
5025 for help in selecting a counselor.
Your local Community Mental Health
Department will help you if you need to
stay in the hospital because of a mental
health issue. Look in the telephone
book for the Community Mental Health
Department in your county.
Durable Medical
Equipment (DME)
Durable Medical Equipment (DME)
includes supplies and equipment needed
for medical purposes to assist in your
health care needs. DME supplies include
things like:
n Diabetic supplies
n Asthma supplies
n Breathing supplies
n Blood pressure cufs
n Diapers
n Wheelchairs
n And many more items
HealthPlus Partners has contracted DME
vendors that participate. Some supplies
can be delivered directly to your home.
Call Customer Service if you have any
questions.
How to Access Hospital
Services
When you select a PCP, you agree to use
his or her hospital afliation. Each PCP is
afliated with a specifc hospital system.
This is the hospital your PCP will use for
inpatient care or other services provided at
a hospital. Your PCP will direct your health
care services provided in the hospital.
Pharmacy Management
For prescriptions, you must use a
participating HealthPlus Partners
pharmacy. Prescriptions should be written
by your PCP, or by a specialist if your PCP
sends you to a specialist.
HealthPlus Partners uses a preferred
drug list. Your doctor has a list of drugs
recommended by HealthPlus Partners.
There are many drugs on this list for your
doctor to choose from.
Your doctor must have our okay to order:
n Brand name drugs when a generic is
available
n Drugs not on our list
n Drugs on our special approval list
Be sure to read the label before taking
any drug.
HealthPlus Partners pays for generic drugs.
These drugs have the same amount of
active medicine as the brand name drug
and meet the same standards. When a
company creates a new drug, it is called a
brand. That company is the only company
that can make and sell that drug until
the patent for the drug expires. Once the
patent expires, another company can
produce the drug under a diferent name.
In order to do so, the drug must have the
same strength, dosage, ingredients and
quality as the brand drug. The new drug is
then called a generic. If your doctor thinks
a brand name drug is medically necessary,
he or she will get approval from HealthPlus
Partners. Your doctor is familiar with the
types of drugs that need approval.
If you choose to get a brand name drug
instead of a generic, you will have to pay
for the full cost of the prescription. Call
HealthPlus Partners toll free at 1-800-332-
9161 if you want more information about
drugs that are covered, drugs on our special
approval list or other drug policies. There is
also information at the HealthPlus Partners
website at www.healthplus.org including
the drug formulary and a drug search tool
that will give you information based on your
own beneft.
Prescription Copays
There are no copays for any prescription
for HealthPlus Partners members
Attention Dual Eligibles (Medicare/
Medicaid) Members
HealthPlus Partners does not cover Part D
drugs. These are covered by your Part D
plan. If you do not have one, you will be
responsible for those drugs. HealthPlus
has suggestions on ways to reduce the
cost of these drugs if you do not have a
Part D plan. Call our Customer Service.
Prior Authorization/ Step
Therapy
You may have to get special approval
before HealthPlus Partners will pay for
some medicines. This is called prior
authorization. If your doctor decides that
you should be taking a drug that is in this
group, he or she can ask the HealthPlus
Partners Pharmacy Department for
prior authorization. Some brand name
drugs may require prior authorization if
there is a generic version available. The
quantity of a medication may also be
limited with prior authorization required
for larger quantities. Some drugs require
step therapy. Step therapy means that
you must try certain frst step drugs
before other second step drugs are
covered. Generic drugs are usually in the
frst step so that treatment starts with
safe, efective and afordable drugs. If
needed, more expensive brand drugs are
usually in the second step. Your doctor
can request prior authorization by faxing
a standard prior authorization request
to the HealthPlus Partners Pharmacy
Department. The request should also
contain an explanation of why he or she
thinks the drug is necessary. Your doctor
can also use this same process to request
any covered medically appropriate drug.
Mandatory Specialty Drug
Program
For some drugs, you must use a
HealthPlus specialty pharmacy (not a
local pharmacy). The pharmacy will mail
the drug to your house or doctors ofce.
This program includes self-injected drugs
for rheumatoid arthritis, hepatitis C and
multiple sclerosis. Your doctor can help
to enroll you with one of the HealthPlus
specialty pharmacies.
For a list of the drugs in this program, you
can go to the Member Pharmacy Center at
the website at www.healthplus.org or you
can call us at 1-800-332-9161.
Vision Services
HealthPlus Partners covers routine vision
exams, frames and lenses. Please refer
to your subscriber contract for specifc
details. Members also may see an in-plan
optometrist/ophthalmologist for medical
vision services, e.g. diabetes, glaucoma,
etc. HealthPlus Partners will cover routine
vision exams, frames, and lenses for
members age 21 and older.
If you are in need of routine eye care, go to
your HPP eye doctor. He or she will check
to see if you are eligible for an exam and
glasses. All other eye care is arranged by
your PCP.
HealthPlus Partners covers low vision
services for members. This includes low
vision glasses, contact lenses, optical
devices, and other related low-vision
supplies and services. These services are
available for specifc eye diseases, eye
trauma and diagnosis. There is a $2 copay
for each service for members age 21 and
older. See your Subscriber Contract for
more details.
Radiology Services
HealthPlus has contracted with CareCore
National to manage radiology services
like MRIs and CT scans. Your doctor will call
CareCore and arrange for these services if
a referral is needed. If a referral is needed,
you will receive a copy once it has been
approved. If another test is better for your
condition, you will receive a notice telling
you this. All letters will list both HealthPlus
Partners and CareCore as the sender. There
is nothing more you need to do. Your doctor
will set up your tests and request the referral
for you. Your doctor will send you directly to
a center for all other x-rays. Your doctor may
be able to perform these services in his or
her ofce. See your PCP for direction.
Substance Abuse
You may have a drug or alcohol problem
if you:
n Drink or take drugs every day
n Lie about drinking or using drugs
n Have money problems because of
drugs or drinking
n Hurt yourself or others when drinking
or using drugs
n Drink or take drugs to feel better
Call for help if this sounds like you.
You can talk to your doctor or the local
coordinating agency that provides
substance abuse services for the name of a
provider. You may fnd a local coordinating
agency at www.michigan.gov/documents/
mdch/AMS_Directory_215002_7.pdf. This
is a beneft under your State of Michigan
Medicaid program.
Family Planning Services
You do not need a referral to see an in
or out of plan family planning provider
for family planning services. This
includes diagnostic evaluations, drugs
supplies, devices, counseling to prevent
or delay pregnancy and the detection
and treatment of STDs. Please see your
subscriber contract for more details.
Call Customer Service toll-free at
1-800-332-9161 for help.
Your Health Benefts
Page 8 Your Health Benefts
Language Interpretation
Services
If you need a language or deaf interpreter
to go to your doctors appointment, call
STAT EMS at 1-888-676-1783 at least 24
hours prior to your appointment and they
will make the needed arrangements. This
allows us to help set up the service so you
are ready for your doctors appointment. If
you need language/translation assistance
for inquiries on benefts, providers, fling a
complaint, etc., you may contact Customer
Service Staf at 1-800-332-9161, Monday
through Friday, 8 a.m. to 6 p.m. TDD users
please call 1-800-992-5070.
Member Materials in Other
Formats
We want to meet the special needs of our
members. Member materials are available
in other languages and formats free of
charge. Please call us to request copies.
Utilization Case
Management Program
If you have special medical needs, the
utilization case management program
at HealthPlus Partners can help you. A
HealthPlus Partners social worker or nurse
case manager will work closely with you
and your doctor to develop a treatment
plan that is best for you. We want you to
get the best care, in the right place.
You can talk to a case manager during the
day. To reach a case manager, call
1-800-332-9161. This is a free call.
If you call after our ofce is closed, the case
manager will call you back the next day.
Care Management Program
We want to make sure that you receive
quality health care. We work with our
providers to:
n make sure that we know about all
your hospital stays and the services
that you may receive
n make sure that you receive any
services you need after you leave the
hospital
n make sure that you receive case
management services if needed
At HealthPlus Partners, we promote
quality health care.
Foster Care Children
The State requires children enrolled in
foster care to have a well child (ESPDT)
physical and mental health screening
within 30 days of entering foster care.
Please call your doctor to set up your
appointment. Our case managers are here
to help. You can also call Customer Service
if you need assistance.
Transportation Program
HealthPlus has contracted with STAT
EMS to provide transportation services.
Representatives are available 24 hours/7
days a week to schedule your services.
This includes meals & lodging, and
interpretation services for eligible
HealthPlus Partners members. To schedule
services call toll free 1-888-676-1783. If
you need a ride to any covered HealthPlus
Partners medical service, call us toll free
at 1-888-676-1783. For transportation
requests you will be transported to
your health care providers ofce if the
following conditions are met.
n You must be a current member with
HealthPlus Partners.
n Your primary care physician has
referred you for the requested
services and the referral is in the
HealthPlus Partners system for
services requiring a referral.
n The request for transportation
has been made according to the
transportation guidelines.
These are the questions you will be asked:
n What is your frst and last name?
n What is your recipient ID?
n What is your home address for pick
up?
n What is your telephone number?
n What is the date and time of the
appointment?
n What is the name of the doctor you
are seeing?
n What is this doctors ofce address?
STAT EMS will follow HealthPlus Partners
transportation policy and guidelines
listed on the next page.
Meals & Lodging
Meals & Lodging are provided when
there is an overnight stay at a hospital for
a HealthPlus Partners member that is 50
miles or more away from your home.
This beneft is provided to one (1) parent
or guardian of a minor child or one spouse
or signifcant other of an adult for short
term assistance.
These services should be scheduled in
advance with STAT EMS. Contact them to
request these services..
Guidelines
1. You must call 1-888-676-1783 to
request services.
2. Requests for bus passes and mileage
reimbursement vouchers must be
called in three to fve business days
before your scheduled appointment.
3. Requests for cab service, if available
in your county, should be called in
24 hours before your scheduled
appointment. Cab services are for
members with special needs, for
senior citizens or in special situations.
All requests, including urgent
requests, will be verifed with your
doctor.
4. Requests for meals & lodging should
Page 9 Your Health Benefts
be scheduled at least 24 hours
in advance through STAT EMS to
allow time to complete the needed
arrangements..
Cancellations
If you need to cancel a scheduled cab ride,
you must call HealthPlus Partners two
hours before your appointment. If you
dont, the ride will be considered a no
show.
No Show Appointments
No show appointments are when cab
rides are scheduled for you, but:
n You didnt give us enough time to
cancel the ride, if necessary
n You didnt use the cab when it arrived
to take you to your appointment
n The cab was sent, then you cancelled
the ride
Page 10 Your Health Benefts
Your Health Benefts
Transportation Sanctions
After your frst no show, you will receive a
letter from HealthPlus Partners with a copy
of the transportation policy. If you have a
second no show, you will no longer be
able to use cab service. You will only be
given bus passes. You will receive a letter
from HealthPlus Partners if this happens.
Make the Most of Your
Health Benefts
Stay Healthy
There are lots of things that you can do to
stay healthy. By doing these things, you may
also lower your chances of becoming ill:
n Eat right
n Exercise
n Control stress
n Stop smoking
n Say no to drugs and alcohol
n Practice safety
Eat Right
The local health department can
help you and your family with your
nutritional needs. To fnd out more about
these programs, call your local health
department.
Childrens Special Health
Care Services (CSHCS)
Childrens Special Health Care Services
(CSHCS) is a State of Michigan program
that serves children, youth and some
adults with special health care needs.
HealthPlus Partners is pleased to ofer
health care services to these families. We
will work with the families to coordinate
the care, address pharmacy and medical
supply needs ordered by their various
doctors including transportation
when needed for services covered by
HealthPlus Partners. CSHCS members
can look forward to the same level of care
HealthPlus Partners provides to all of its
members. It is this that we welcome you to
our HealthPlus family!
How to Enroll in CSHCS
CSHCS covers more than 2,700 medical
diagnoses. CSHCS helps persons with
chronic health problems. There are
additional benefts provided that are listed
in the Your Beneft section of this book.
To join, children and some adults must
have a qualifying condition. Some
examples of medical conditions include:
n Cancer
n Cerebral Palsy
n Cleft Palate, Cleft Lip
n Liver Disease
n Deformed Limbs, Amputations
n Certain Vision Disorders
n Cystic Fibrosis
n Other Chronic Lung Conditions
n Hearing Loss
n Insulin Dependent Diabetes
n Muscular Dystrophy
n Certain Heart Conditions
n Epilepsy
n Neurological Disorders
n Kidney Disease
n Sickle Cell Anemia
n Paralysis
n Spinal Injuries and many more
HealthPlus Partners will assist members
who feel they may qualify and submit the
needed materials to MDCH to determine
eligibility for this program. Contact
HealthPlus Customer Service toll free at
1-800-332-9161 for more information.
Your HealthPlus Partners
Identifcation Card
Your identifcation card lists you as a
member who is covered by HealthPlus
Partners. If any information on the card is
incorrect, please call Customer Service (24
hours a day, 7 days a week) at
1-800-332-9161 or visit us at
www.healthplus.org with the correct
information as soon as possible.
Each member will get a HealthPlus
Partners card and a green mihealth (My
Health) card from the State (see page 2).
You will need both cards to get services. If
you lose your HealthPlus Partners card, or
if the information changes, call us toll free
at 1-800-332-9161.
Your HealthPlus Partners card provides the
following information:
1. Group Number
Indicates group or individual coverage
2. Coverage
Identifes your beneft level
3. Efective Date
The date your current coverage became
efective
4. Recipient ID Number
Member identifcation number.
5. Member Name
Member name
6. Primary Care Physician (PCP) Name
Name of members PCP
7. PCP Telephone
PCP ofce telephone number
8. Hospital
Hospital your doctor uses and where
you will be sent, if needed.
9. CSHCS
Identifes you as a HealthPlus Partners
Childrens Special Health Care Services
Member.
Always show both of your cards when you
receive care. Do not allow anyone else to
use your identifcation card. Improper use
of your card is considered fraud and can
result in the cancellation of your health
care coverage with HealthPlus Partners. If
you lose your identifcation card, or require
additional cards, please contact Customer
Service or visit us on the Web at
www.healthplus.org.
Your identifcation card is also important
if you are hospitalized. Please notify
HealthPlus Partners in the event that a
hospitalization occurs. The back of your
card has the telephone number to call.
Always have your card handy when you
call or visit HealthPlus Partners. This helps
us serve you quickly and efciently.
Childrens Special Health Care Services
RXBIN 610011 RXPCN 23050
RECIPIENT NUMBER
1234567890
RECIPIENT NAME
JOHN DOE
PCP NAME/TELEPHONE#
DR. SMITH
Hometown Regional Medical Center
EFFECTIVE DATE
OF COVERAGE
01/01/11
GROUP
#98765C
(810) 750-6060
Aproduct of HealthPlus of Michigan, Inc.
CSHCS
BP = A3
NLDICAID PLAN
Page 11 Childrens Special Health Care Services
9.
2.
3.
1.
7.
4.
5.
6.
8.
Your CSHCS Health Benefts
A brief summary of your benefts are
listed on this page. You must see your
PCP or be referred for care except as
otherwise stated in this handbook.
Please refer to your Subscriber Contract
for a more detailed description of your
benefts.
Remember, all services provided by
non-participating doctors (except for
medical emergencies) should be okayed
your PCP. There are no copays for CSHCS
members.
Page 12 Your CSHCS Health Benefts
Here are your benefts: Here is how to use them:
Primary Care Services
Ofce visits
Well child visits includes the developmental/behavioral health
Baby shots
Lab and X-rays
Specialist services okayed by your PCP
Medically necessary weight loss services
End Stage Renal Disease
Maternity care
Pre and post-natal services
Certifed nurse midwife services
Call your PCP for an appointment
Your PCP will arrange for your care
Go to your PCP or any in-plan OB/GYN
Inpatient Hospital Services
Semi-private room Doctor Surgery care Maternity care
Diagnostic care Lab and X-ray Drugs and supplies
Organ and tissue transplants
Your PCP will arrange for your care
Outpatient Hospital Services
Lab and X-rays Outpatient surgery Diagnostic testing
Your PCP will arrange for your care
Emergency Care
Medical care Ambulance
Go to nearest emergency room or call 911
Urgent Care After Hours Call your PCP and/or go to an After Hours Clinic
Pharmacy Services
Prescription drugs Some over-the-counter items
Family Planning Services
Exam
Birth control
Sterilization (must be 21 years old)
See Subscriber Contract for limitations
Infertility screening and diagnosis
Screening and treatment for sexually transmitted diseases (STD)
Go to your PCP or a Family Planning provider
Your PCP will arrange for your care
Hearing and Speech
Diagnostic services
Hearing aids covered for members under the age of 21
Hearing aid batteries
Your Doctor will arrange for your care
Mental Health Services
Twenty visits each year
Members can choose any participating counselor, but may want to ask their
PCP or HealthPlus Partners at 1-800-555-5025 for help in selecting a counselor.
Vision
One eye exam every two years
Glasses every two years
Replacement glasses
Call your HPP vision provider to arrange for routine eye care.
Medical Equipment
Medical supplies Durable Medical Equipment
Prosthetics and orthotics
Your Doctor will arrange for your care
Other Services
Home health care Chiropractic services Podiatrist services Oral surgery and related services Allergy testing and treatment
Short-term outpatient rehabilitative therapy (physical, occupational, speech and language)
Short-term restorative or rehabilitative services in nursing facility Blood lead screening, treatment and follow up
Health education Parenting and childbirth classes Certifed pediatric and nurse practitioner services
Out-of-state services Hospice services Midwife services Treatment for communicable diseases
Your PCP will arrange for your care when needed
assessment
Additional Benefts for
Childrens Special Health
Care Services Health Plan
Members
These are benefts covered either through
FFS Medicaid using your green mihealth
card or by calling the agency listed below
1. Help form your Local Health
Department with:
l
Community resources schools,
community mental health,
fnancial support, childcare, Early
On, and the Women Infants and
Children (WIC) program
l
Transitioning to adulthoold
l
Orthodontia
n
Only or specifc CSHCS
qualifying diagnosis such as
Cleft Palate/Cleft Lip
n
Medically necessary, related to
condition
n
Not for cosmetic purposes
l
Respite
n
CSHCS covers 180 hours of
respite care annually when a
benefciary requires skilled nurs-
ing and a CSHCS nurse consul-
tant determines appropriate.
2. Help from the Family Center for
Children and Youth with Special
Health Care Needs
l
CSHCS Family Phone Line a toll
free phone number (1-800-359-
3722) available Monday through
Friday from 8 am to 5 pm
l
Parent-to-parent support network
l
Parent/Professional training
programs
l
Financial help to go to conferences
about CSHCS medical conditions
and Relatively Speaking, a confer-
ence for siblings of children with
special needs.
3. Help from the Childrens Special
Needs (CSN) Fund. The CSN 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:
l
Wheelchair ramps
l
Van lifts and tie downs
l
Therapeutic tricycles
l
Air conditioners
l
Adaptive recreational equipment
l
Electrical service upgrades for
eligible equipment
Services Not Covered
by HealthPlus Partners
But Covered by the State
Medicaid Program
We do not pay for these services. We
would be happy to help you contact the
right agency.
1. Long-term basic care services Contact
HealthPlus Partners case management
for assistance
2. Substance abuse services
Contact your local coordinating agency
3. Inpatient mental health services
Contact your local community mental
health agency
4. Routine dental care
See any dental provider who accepts
Medicaid
5. Transportation for care or services
not covered by HealthPlus Partners
Contact your case worker
6. Mental health after 20 outpatient
visits
Contact your local community mental
health agency
7. Outpatient partial psychiatric hospital
care
Contact your local community mental
health agency
8. Personal care or home help services
Contact your case worker
9. Some school services billed by
intermediate school districts
Contact your local school district
10. Some developmental disability care
Contact your local community mental
health agency
11. Home and community-based waiver
services
Contact your case worker
12. Intermittent or short-term restorative
or rehabilitative services (in a nursing
facility), after 45 days
Contact the State Benefciary Help Line
13. Traumatic brain injury program
services
Contact the State Benefciary Help Line
14. Substance abuse medications,
antipsychotic medications
and, other behavioral health
medications, medications for HIV/
AIDS, medications to treat bleeding
disorders and some rare metabolic
conditions
15. Maternal Infant Health Program
(MIHP) Services
Contact your local MIHP provider or
HPP for assistance in locating one near
you.
16. Orthodontia
Use your mihealth card to access these
services.
These are covered by the State of Michigan
through your mihealth card.
Services Not Covered by
HealthPlus Partners or
by the State Medicaid
Program
We do not pay for these services nor does
the State Medicaid Program. You will have
to pay for these services:
1. Elective abortions and related
services (covered only if given to
save the life of the mother or to end
a pregnancy resulting from rape or
incest)
2. Acupuncture
3. Experimental/investigational drug
procedures or equipment
4. Elective cosmetic surgery
5. Any services not medically necessary
6. Treatment for infertility
Page 13 Your CSHCS Health Benefts
Medicare/Medicaid Members
NLDICAID PLAN
RXBIN 610011 RXPCN 23050
RECIPIENT NUMBER
1234567890
RECIPIENT NAME
JOHN DOE
PCP NAME/TELEPHONE#
DR. SMITH
Hometown Regional Medical Center
EFFECTIVE DATE
OF COVERAGE
01/01/11
GROUP
#98765D
(810) 750-6060
Aproduct of HealthPlus of Michigan, Inc.
Medicare/Medicaid
Member
BP = A1
Medicare/Medicaid
Members
Medicare/Medicaid members sometimes
referred to as Dual Eligibles can now
remain enrolled with HealthPlus as long as:
1. You are receiving both Medicare and
Medicaid benefts,
2. You have HealthPlus Medicare
Advantage, or
3. You have Fee -For-Service Medicare
(straight Medicare).
Fee-For-Service Medicare means you have
to use your traditional red, white and blue
Medicare card for your Medicare benefts.
You would not be part of any health plan
for your Medicare benefts.
Your HealthPlus Partners
Identifcation Card
Your identifcation card lists you as a
member who is covered by HealthPlus
Partners. If any information on the card is
incorrect, please call Customer Service (24
hours a day, 7 days a week) at
1-800-332-9161 or visit us at
www.healthplus.org with the correct
information as soon as possible.
Each member will get a HealthPlus
Partners card and a green mihealth (My
Health) card from the State (see page 2).
You will need both cards to get services. If
you lose your HealthPlus Partners card, or
if the information changes, call us toll free
at 1-800-332-9161.
Your HealthPlus Partners card provides the
following information:
1. Recipient ID Number
Member identifcation number.
2. Efective Date
The date your current coverage
became efective.
3. Member Name
Member name.
4. Group Number
Indicates group or individual
coverage.
5. Primary Care Physician (PCP) Name
Name of members PCP.
6. PCP Telephone
PCP ofce telephone number.
7. Hospital
Hospital your doctor uses and where
you will be sent, if needed.
8. Coverage
Indicates your beneft package
9. Medicaid/Medicare Member
Identifes you as a HealthPlus Partners
Medicare/Medicaid Member.
Always show both of your cards when you
receive care. Do not allow anyone else to
use your identifcation card. Improper use
of your card is considered fraud and can
result in the cancellation of your health
care coverage with HealthPlus Partners.
If you lose your identifcation card, or
require additional cards, please contact
Customer Service or visit us on the web at
www.healthplus.org.
Your identifcation card is also important
if you are hospitalized. Please notify
HealthPlus Partners in the event that a
hospitalization occurs. The back of your
card has the telephone number to call.
Always have your card handy when you
call or visit HealthPlus Partners. This helps
us serve you quickly and efciently.
Choosing the Right Primary
Care Physician (PCP)
You must choose a HealthPlus Partners
Primary Care Physician (PCP) as your main
doctor. When choosing a doctor, think
about what is important to you and your
family. You may want to choose a doctor
close to your home or your childrens
school. You may choose a doctor in family
practice, internal medicine, a pediatrician
for your child or a doctor at a clinic. If
you choose a pediatrician as your childs
PCP, you do not need a referral for these
services. All of these doctors provide
primary care, but in diferent ways.
We will work to make sure the PCP you
have listed for Medicare is also the same
PCP for Medicaid.
Family Practice doctors give health care
to male and female patients of all ages and
health problems. They can also be your
childs pediatrician. Some deliver babies
and take care of womens health needs.
Internists give care to adults with both
regular health care needs and special
problems.
Federally Qualifed Health Centers
(FQHCs) give care to male and female
patients of all ages and health problems.
They also provide other services not
covered by HealthPlus Partners, but are
covered by the State such as dental care.
You may go to any FQHC in any county
without a referral from your PCP. You may
also choose to get your services from one
of the FQHCs listed below by choosing
them as your PCP:
n Hamilton Family Health Center
(Genesee County)
n Health Delivery Inc.
(Saginaw, Bay, and Shiawassee
Counties)
Clinics are stafed with resident doctors
who must spend an extra three to fve
years in training for their specialty. Board
Page 14 Medicare/Medicaid Members
continues on page 16
9.
8.
2.
4.
6.
1.
3.
5.
7.
Your Medicare/Medicaid Health Benefts
Here are your benefts: Here is how to use them:
Primary Care Services
Ofce visits
Well child visits
Baby shots
Lab and X-rays
Specialist services okayed by your PCP
Medically necessary weight loss services
End Stage Renal Disease
Maternity care
Pre and post-natal services
Certifed nurse midwife services
Call your PCP for an appointment
Your PCP will arrange for your care
Go to your PCP or any in-plan OB/GYN
Inpatient Hospital Services
Semi-private room Doctor Surgery care Maternity care
Diagnostic care Lab and X-ray Drugs and supplies
Organ and tissue transplants
Your PCP will arrange for your care
Outpatient Hospital Services
Lab and X-rays Outpatient surgery Diagnostic testing
Your PCP will arrange for your care
Emergency Care
Medical care Ambulance
Go to nearest emergency room or call 911
Urgent Care After Hours Call your PCP and/or go to an After Hours Clinic
Pharmacy Services
Prescription drugs Some over-the-counter items
Family Planning Services
Exam
Birth control
Sterilization (must be 21 years old)
See Subscriber Contract for limitations
Infertility screening and diagnosis
Screening and treatment for sexually transmitted diseases (STD)
Go to your PCP or a Family Planning provider
Your PCP will arrange for your care
Hearing and Speech
Diagnostic services
Hearing aids covered for members under the age of 21
Hearing aid batteries
Your Doctor will arrange for your care
Mental Health Services
Twenty visits each year
Members can choose any participating counselor, but may want to ask their
PCP or HealthPlus Partners at 1-800-555-5025 for help in selecting a counselor.
Vision
One eye exam every two years
Glasses every two years
Replacement glasses
Call your HPP vision provider to arrange for routine eye care.
Medical Equipment
Medical supplies Durable Medical Equipment
Prosthetics and orthotics
Your Doctor will arrange for your care
Other Services
Home health care Chiropractic services Podiatrist services Oral surgery and related services Allergy testing and treatment
Short-term outpatient rehabilitative therapy (physical, occupational, speech and language)
Short-term restorative or rehabilitative services in nursing facility Blood lead screening, treatment and follow up
Health education Parenting and childbirth classes Certifed pediatric and nurse practitioner services
Out-of-state services Hospice services Midwife services Treatment for communicable diseases
Your PCP will arrange for your care when needed
A brief summary of your benefts are listed
on this page. You must see your PCP or be
referred for care except as otherwise stated
in this handbook. Please refer to your
Subscriber Contract for a more detailed
description of your benefts.
Remember, all services provided by
non-participating doctors (except for
medical emergencies) should be okayed
your PCP. There are no copays for
Medicare/Medicaid members.
Page 15 Your Medicare/Medicaid Health Benefts
certifed doctors supervise them. When
you choose a clinic as your doctor, you
will see any of the resident doctors seeing
patients on that day.
GENESEE COUNTY
n Mott Childrens Health Center-
Northwestern HS
n Mott Childrens Health Center-
Beecher/Dolan MS
n Mott Childrens Health Center
SAGINAW COUNTY
n Saginaw CHD-Bridgeport/Spaulding
and Thurston MS
n Saginaw CHD-Ricker MS
n Health Delivery, Inc-Saginaw HS
n Health Delivery, Inc-Arthur Hill HS
SHIAWASSEE COUNTY
n Shiawassee County Health
Department-Durand MS/HS
Turning 65?
If you are 65 and becoming Medicare
eligible, contact your local Social Security
ofce to fnd out about your Medicare
eligibility. Once you have Medicare, please
call and give us that information. If the local
Social Security ofce tells you that you do
not qualify, please tell us that as well.
DCH notifes us of individuals who are turn-
ing 65 and automatically moves them to a
Medicare/Medicaid member category. Per
MDCH policies, all claims will deny for
Medicare primary coverage until Health-
Plus is notifed that you have Medicare
coverage or that you do not qualify.
To assist you, we will send a reminder letter
to you. This way you can contact your local
Social Security ofce quickly and we can
then update our system.
Part B Coverage
Some Medicare/Medicaid members are
eligible for Medicare Part B coverage.
Part B covers ofce visits to your doctors
appointments. HealthPlus would then pay
any copays, cost sharing, and deductibles.
Once enrolled in Part B, MDCH will pay
your Part B premium for you. So there is no
out of pocket cost to you. If you would like
assistance signing up for Part B, contact
your local Valley Area Agency on Aging toll
free at 1-800-803-7174.
There is no copay for any prescription for
members under 21 years of age. Please
talk with your doctor about your options.
Part D Drugs
Attention Medicare/ Medicaid
members! HealthPlus Partners does not
cover Part D drugs. These are covered by
your Part D Plan. If you do not have one,
you will be responsible for those drugs.
HealthPlus has suggestions on ways to
reduce the cost of these drugs if you do
not have a Part D Plan. Call Customer
Service at 1-800-332-9161. You can also
contact your local Valley Area Agency
on Aging toll free at 1-800-803-7174 for
assistance in selecting a Part D Plan.
Services Not Covered
by HealthPlus Partners
for Medicare/Medicaid
Members but Covered
by the State Medicaid
Program
We do not pay for these services. We
would be happy to help you contact the
right agency .
1. Long-term basic care services
Contact HealthPlus Partners case
management for assistance
2. Substance abuse services
Contact your local coordinating agency
3. Inpatient mental health services
Contact your local community mental
health agency
4. Routine dental care
See any dental provider who accepts
Medicaid
5. Transportation for care or services not
covered by HealthPlus Partners
Contact your case worker
6. Mental health after 20 outpatient visits
Contact your local community mental
health agency
7. Outpatient partial psychiatric hospital
care
Contact your local community mental
health agency
8. Personal care or home help services
Contact your case worker
9. Some school services billed by
intermediate school districts
Contact your local school district
Medicare/Medicaid Members
Page 16 Medicare/Medicaid Members
10. Some developmental disability care
Contact your local community mental
health agency
11. Home and community-based waiver
services
Contact your case worker
12. Intermittent or short-term restorative
or rehabilitative services (in a nursing
facility), after 45 days Contact the
State Benefciary Help Line
13. Traumatic brain injury program
services
Contact the State Benefciary Help Line
14. Substance abuse medications,
antipsychotic medications and,
other behavioral health medications,
medications for HIV/AIDS, medications
to treat bleeding disorders and some
rare metabolic conditions.
15. Maternal Infant Health Program
(MIHP) Services
Contact your local MIHP provider or HPP
for assistance in locating one near you.
These are covered by the State of Michigan
through your mihealth card.
Services Not Covered by
HealthPlus Partners or
by the State Medicaid
Program
We do not pay for these services nor does
the State Medicaid Program. You will have
to pay for these services:
1. Elective abortions and related services
(covered only if given to save the life
of the mother or to end a pregnancy
resulting from rape or incest)
2. Acupuncture
3. Experimental/investigational drug
procedures or equipment
4. Elective cosmetic surgery
5. Any services not medically necessary
6. Treatment for infertility
7. Part D drugs
For Medicare/Medicaid Members ,
HealthPlus does not cover drugs covered
by Medicare Part D. You should have a Part
D program. If you do not, these drugs are
your responsibility. Please refer to your
Subscriber Contract for details of covered
and non-covered services. Contact your
local Valley Area Agency on Aging toll free
for assistance in selecting a Part D program.
Womens Health
Janets Law
There is a law called the Womens Health
& Cancer Rights Act of 1998. This Act is
also known as Janets Law.
Your HealthPlus Partners Subscriber
Contract explains the medical and
surgical benefts in connection with a
mastectomy as provided by this Act. If
you have had a mastectomy and wish to
elect breast reconstruction in connection
with the mastectomy, please note that the
following coverage is available to you.
1. Reconstruction of the breast on
which the mastectomy has been
performed;
2. Surgery and reconstruction of
the other breast to produce a
symmetrical appearance;
3. Prostheses, if prosthetic devices are
listed as a covered service in your
Beneft Rider; and
4. Care for physical complications
from all stages of the mastectomy,
including lymphedemas.
The above described coverage must be
provided in a manner determined in
consultation with you and your attending
physician.
Finally, please note that the above
described coverage is subject to any
applicable copays as provided in your
Subscriber Contract.
If you have any questions, please call
Customer Service at 1-800-332-9161.
Womens Health Services
You do not need a referral to see an in-plan
OB/GYN doctor to have a baby or for your
routine, yearly check up or womens health
specialists for routine preventive health.
Ask your PCP for the name of an in-plan
OB/GYN doctor, or call Customer Service
toll-free at 1-800-332-9161 for help.
Having a Baby?
If you are pregnant, you can see your PCP
or an in-plan OB for prenatal care. You do
not need a referral for this service. New
members who are pregnant at the time
of enrollment with HealthPlus Partners
are allowed to choose or remain with the
OB provider of your choice in- or out-
of-network for prenatal care without a
referral. Listed below are some things you
can do to take care of yourself so that you
can have a healthy baby.
1. Make sure that you go to all of your
appointments. Your doctor will check
to make sure that both you and the
baby are healthy.
2. Dont smoke, drink alcohol or do
drugs. Your baby can be afected by
almost everything that you eat or
drink.
3. Eat healthy foods. Try green leafy
vegetables that are high in folic acid.
These foods will help your body stay
strong. It also helps your babys brain
develop well.
4. Practice safe sex. Sexually transmitted
diseases can cause many problems
for your baby.
5. Wear your seat belt.
6. Exercise.
7. Relax and accept your feelings.
Listed below is a guide to help you
schedule your visits during and after
pregnancy:
HealthPlus Partners has lots of providers to
choose from. You may also see a certifed
nurse midwife for prenatal care. Please call
Customer Service at 1-800-332-9161 if you
need assistance.
State of your
pregnancy
When to see your
doctor
Before 14 weeks (or as
soon as you think you may
be pregnant
Go for your frst
prenatal visit as soon as
possible
Between 14 and 28 weeks Every 4 weeks
Between 29 and 36 weeks Every 2 weeks
Between 37 and 40 weeks Every week
After your baby is born
Postpartum checkup
between 21 and 56
days after delivery
Childbirth Education
Classes
During pregnancy, your body goes
through various changes you may be
unaware of. Childbirth education classes
will help you understand these changes
and help prepare you for delivery and
taking care of your baby after the delivery.
HealthPlus Partners covers these classes
provided by qualifed educators at most
hospitals or through certifed Maternal
Infant Health Programs. Please see your
doctor for a referral.
Maternal Infant Health
Program (MIHP)
You may join the Maternal Infant Health
Program (MIHP). This program has a health
care team to help you have a healthy
pregnancy.
n It helps you learn about your new
baby.
n You must qualify for MIHP. Check with
your doctor if you would like to join.
The MIHP is covered by the State of
Michigan. You must use your mihealth
card for these services. Dont forget to go
back to your doctor after you have your
baby. This follow up visit is very important.
Call you doctor or HealthPlus for assistance
in locating a MIHP provider.
Page 17 Womens Health
Post-Partum Care
Once your baby is born, you will need
to see your PCP or OB for what is called
post-partum care. This check up is not your
initial visit, but usually occurs between
three and six weeks after you have your
baby to make sure youre okay. It is
important that you make and keep this
appointment
Women, Infants
and Children (WIC)
Supplemental Food &
Nutrition Program
WIC is a health and nutrition program that
has shown a positive efect on pregnancy
and child growth. WIC members get help
with:
n Healthy eating
n Breastfeeding
n Referrals to other health services
Coupons are given so you can buy fresh
produce, dairy and cereal items. Call the
local health department to fnd out more
about the WIC program.
Get Tested for Chlamydia
Chlamydia is the most common sexually
transmitted disease (STD) in Michigan and
the United States. Most of the time, the
person with the disease does not feel sick
at all. You can get chlamydia by having sex
without using a condom. If left untreated,
it can lead to pelvic infammatory disease
(PID). PID is an infection of the female
reproductive organs. If this happens,
the woman might not be able to get
pregnant. If you are pregnant and get
chlamydia, your baby could get an eye
infection, pneumonia or even die. If you
have chlamydia, you are at greater risk of
getting HIV.
A germ called bacteria causes chlamydia.
Bacteria are very easy to test for. They
also are easy to treat with antibiotics. You
should get tested for chlamydia if any of
the following is true:
n Are 16 to 25 years old and sexually
active
n Have had an abnormal Pap smear
n Have a new male sex partner or have
more than two partners in a year
n Dont always use a condom
n Have or had another STD
The test for chlamydia is quick and
painless. If it comes back showing
chlamydia, it is important to take all of
the medicine the doctor gives you. Its
important that the male sex partner be
treated, too.
HealthPlus Partners cares about your
health. Chlamydia testing is covered by
HealthPlus Partners.
Dont Forget Your Pap Test!
If you are sexually active, it is important
that you have a pelvic exam at least every
three years. The pelvic exam includes a
Pap test. The Pap test screens for cancer
of the cervix. This cancer often causes no
pain, so having regular Pap tests is vital.
The sooner cervical cancer is found, the
easier it is to treat.
How to Detect Breast
Cancer
Finding breast cancer early is the best
strategy for successful treatment. All
women should have a yearly breast exam
done by a provider or clinician every one
to two years. Mammograms should be
done every one to two years starting
at age 40. Mammograms are the most
efective way to detect breast cancer when
lumps are too small to be felt or seen.
Mammography is not painful, although it
can be uncomfortable.
Colorectal Cancer
Colorectal cancer is the second leading
cause of cancer-related deaths Michigan
for men and women combined.. If
everyone age 50 to 75 years of age had
regular screening tests, at least one-third
of deaths from this cancer could be
avoided. Everyone is at risk of developing
colorectal cancerall men, all women,
all races. Screening for colorectal cancer
not only detects the disease at ab early,
curable stage, but it can also prevent if by
fnding and removing polys that might
become cancer. Please talk to your doctor
about the simple screening tests available.
Symptoms of cancer may be:
n Blood in or on your stool (bowel
movement)
n Stomach aches, pains or cramps that
happen a lot and you dont know
why
n A change in bowel habits, such as
having stools that are narrower than
usual
n Losing weight and you dont know
why
If you have any of these symptoms, talk to
your doctor about being screened.
High Blood Pressure
High blood pressure is known as a silent
killer because it usually has no symptoms.
Left unchecked, high blood pressure
can cause heart attacks, strokes, kidney
damage, eye damage and other serious
problems. High blood pressure can be
controlled. A blood pressure reading
greater than 120/80 puts you in the pre-
hypertension range. A measurement
of 140/90 or higher is considered high
blood pressure. Many things can raise
blood pressure temporarily so have blood
pressure readings at diferent times over a
few weeks or months. If the numbers are
120/80 or above, make lifestyle changes to
lower your blood pressure. If the numbers
are 140/90 or above, see your doctor and
follow his or her advice.
Page 18 Womens Health
Womens Health
cant see, taste or smell lead. You may have
lead in the dust, paint or soil in and around
your home or in your drinking water or
food. Because it does not break down
naturally, lead can remain a problem until
it is removed.
The long-term efects of lead in a child
can be severe. They include learning
disabilities, decreased growth, hyper-
activity, impaired hearing and even brain
damage. Many times there are no visible
signs of lead poisoning. If caught early,
these efects can be limited by reducing
exposure to lead or by medical treatment.
In Michigan, all children enrolled in
Medicaid should be tested for lead
preferably before two years of age.
Please call your doctor to have your
child tested.
Immunizations (Shots)
Having your child immunized is one of
the most important ways you can protect
against serious diseases. Immunizations
(or shots) are very safe. When you take
your child for a checkup, be sure his or her
immunization record is checked and that
you receive all recommended vaccines,
including a vaccine against pneumococcal
diseases. Be sure you get a copy of the
immunization record to take home with
you!
Colds and Sore Throats
When your child is sick, you want to do
everything you can to help. Viruses cause
the common cold, most coughs and the
fu. Antibiotics wont work on viral illnesses
to help your child feel better. Using
antibiotics for a cold or runny nose will not
cure it or help the child feel better. Sore
throats are sometimes caused by bacteria.
Antibiotics do work against bacteria
and may be prescribed to treat the sore
throat. Be sure to give your child all of the
medicine prescribed. Talk to your doctor to
learn more about the use of antibiotics.
Childrens Health Mens Health
Prostate Cancer
Prostate cancer is now the most common
cancer among males. Men who are at the
greatest risk for developing it are those:
n Over age 45
n Who have a history of prostate cancer
in the family
n Who eat a diet high in fat
n Who are African American
Prostate cancer strikes black men more
often than white men. Prostate cancer is
often slow-growing. In many cases, it can
be cured if it is treated before it spreads.
Prostate cancer may have no symptoms or
symptoms may include:
n Frequent urination
n Difculty starting urination
n Incomplete emptying of bladder
n Blood or pus in urine
n Blood in semen
n Low back pain
n Interrupted urine stream
n Weak urine stream
Talk to your primary care doctor at your
next visit about which prostate screening
test is best for you. The prostate screening
with a Prostate Specifc Antigen (PSA) test
may be appropriate for men age 50-65.
Childrens Health / Mens Health
Well Child Visits
Keep your child healthy! Make an
appointment for your child to get a well
child visit, sometimes called EPSDT. At
this visit, the doctor will do a physical and
give any needed shots. He or she will also
do a vision and hearing screening and
make sure that your child is doing what
is expected for his or her age. Your doctor
also will make referrals for any needed
follow-up services.
A well child visit is important so the doctor
can see your child and talk to you about:
n Eyes, ears, height, weight and
lungs; check for normal growth and
development
n Safety, injury and violence protection
n Risk for obesity, diabetes or heart
disease
n Lead poisoning (screening/testing at
age 1 and again before age 2 years; if
not, it should be done between 3 to 6
years)
n Shots
Babies and children should have well child
visits at the following ages:
n 2 to 4 days after birth
n 1 month
n 2 months
n 4 months
n 6 months
n 9 months
n 12, 15, 18 months
Then, every child should have a yearly well
child exam annually from age 2 to 6, every
other year from 7 to 10 years of age and
then annually from 11 to 21 years of age.
A good way to remember is to make the
appointment after his or her birthday.
Lead Testing
Many things in our everyday lives put
infants, children and adults in danger of
lead poisoning. About one in 22 children
in America have high levels of lead in their
blood, according to the Centers for Disease
Control and Prevention.
You may have lead around your building
or home without knowing it because you
Page 19
Health and Wellness
Colorectal Cancer
Colorectal cancer is the second leading
cause of cancer-related deaths Michigan
for men and women combined.. If
everyone age 50 to 75 years of age had
regular screening tests, at least one-third
of deaths from this cancer could be
avoided. Everyone is at risk of developing
colorectal cancerall men, all women,
all races. Screening for colorectal cancer
not only detects the disease at ab early,
curable stage, but it can also prevent if by
fnding and removing polys that might
become cancer. Please talk to your doctor
about the simple screening tests available.
Symptoms of cancer may be:
n Blood in or on your stool (bowel
movement)
n Stomach aches, pains or cramps that
happen a lot and you dont know
why
n A change in bowel habits, such as
having stools that are narrower than
usual
n Losing weight and you dont know
why
If you have any of these symptoms, talk to
your doctor about being screened.
High Blood Pressure
High blood pressure is known as a silent
killer because it usually has no symptoms.
Left unchecked, high blood pressure
can cause heart attacks, strokes, kidney
damage, eye damage and other serious
problems. High blood pressure can be
controlled. A blood pressure reading of
120/80 puts you in the pre-hypertension
range. A measurement of 140/90 or
higher is considered high blood pressure.
Many things can raise blood pressure
temporarily so have blood pressure
readings at diferent times over a few
weeks or months. If the numbers are
120/80 or above, make lifestyle changes to
lower your blood pressure. If the numbers
are 140/90 or above, see your doctor and
follow his or her advice.
HealthQuest
HealthPlus Partners has access to special
programs called HealthQuest Health and
Wellness. HealthQuest programs and
information can help you learn how to stay
healthy and live better. HealthQuest staf
work side by side with your doctors to give
you accurate information about ways to
lower your risk of getting really sick.
HealthQuest has programs that
emphasize:
n The importance of prevention, early
detection, screening and vaccinating
children
n The importance of regular visits to
the doctor for children, teenagers and
adults
n The importance of prenatal care and
good nutrition for mothers-to-be
n Womens health, including
mammograms, Pap smears and the
management of menopause
n Treatment for depression and mental
health concerns
n The importance of learning how to
live with asthma and diabetes
n The importance of controlling high
blood pressure
n Ways to reduce cardiovascular
disease (strokes, heart attacks and
high cholesterol)
n How to start an exercise program
n How to stop smoking
n How to eat healthy & better manage
your weight
For a list of programs and information,
please call the HealthQuest Department
toll-free at 1-800-345-9956, ext. 1943.
HealthQuest Online Health
and Wellness
To access our online wellness and health
information center, go to
www. healthplus.org and select the Health
& Wellness button. This button will take
you to all kinds of health information on
hundreds of health topics. Our health
encyclopedia has more than 1,800 health
topics. The online library has hundreds of
articles and health facts to help you and
your family get and stay healthy. There are
also many online tools and quizzes you
can use to help you and your family get
and stay healthy.
Stop Smoking Programs
HealthPlus Partners can help you end
your tobacco habit. Our programs and
resources are designed to help you
consider the benefts of ending a smoking
habit. It will also ofer help when you are
ready to quit. HealthPlus Partners ofers a
variety of tools and materials to help you
in the quitting process. The program helps
smokers (and former smokers) in a way
that meets your personal needs. Programs
can include:
n Phone coach cessation program
n Home stop smoking materials
n Internet programs and information
n Discounts for local programs
n Medications
All programs and materials are free to
members. Medications may be subject to
copays.
To enroll in any of the programs or to
request information call 1-800-345-9956,
ext. 1943, option 2, or email us at
hquest@healthplus.org.
Weight Management
Programs & Services
iCanChange Phone Coaching:
Available to members whose weight
puts them at risk for developing disease
and may already have chronic health
conditions such as high blood pressure
and/or diabetes. Members will have the
advantage of the iCanChange online
coaching as well as phone coaching
and an iCanChange kit that includes a
workbook, pedometer and measuring
tape. Members will be assigned to a
personal health coach who will motivate
and help them with weight management
for one year!
Members can also choose from a variety of
Page 20 Mens Health / Health and Wellness
Mens Health
weight loss resources that include:
n Discounts for local programs
n Home weight loss kits
n Internet programs information
You must qualify for some programs by
meeting criteria defned by HealthPlus
Partners. To enroll, call 1-800-345-9956,
ext. 1943, option 3 or email hquest@
healthplus.org.
HealthQuest Self-Help
Information Support
Knowledge is power! HealthPlus can help
you learn more about a medical condition
or how to lead a healthier life. Our goal is
to make sure you have the facts to make
good health choices. You ask the question,
we will get the information to you on
almost ANY health topic. Here are some
topics that you can get from HealthPlus:
n Planning a Healthy Pregnancy
n Caring for your Newborn
n Cholesterol Control
n Eating and Exercising for Better
Health
n Living with Cancer
n Living with Diabetes
n Helping Your Child Manage Asthma
n Managing Stress
n Managing Anxiety Disorders
n Help for Depression
n Controlling High Blood Pressure
n Take Care of Your Back
To order information, call HealthQuest toll-
free at 1-800-345-9956, ext. 1943 or e-mail
us at hquest@healthplus.org.
HealthQuest Toll Free
Health Information Line
Members can access our Health
Information line 24 hours a day to request
any health information they might need.
There is a menu that directs members
to general topics as well as an option to
request any information they may need. To
access the line, members can call
1-800-345-9956, ext. 1943 and select from
the following options and press option:
1. Information about childrens lead
testing
2. Tobacco Cessation
3. Weight Management
4. Disease Management Programs
5. Mens or Womens Health
6. Pregnancy
7. HealthQuest Perks discount
programs
0. To leave a message
Community Resources
For your convenience, HealthQuest
maintains a list of health education classes
and resources ofered in your community.
Classes are listed by topic, county and
provider. Some programs and services
are free. Others charge a fee. Some
community resource classes and programs
are not covered by HealthPlus Partners.
You may be responsible for any fees.
For a list of classes and programs in your
area, call HealthQuest toll-free at
1-800-345-9956, ext. 1943 and choose
option 0 to leave a message.
HealthQuest Perks
Program
HealthPlus is continually looking for ways
to show members that we appreciate
them. In an efort to help you reach your
health goals, lower your risk of health
concerns, and feel better about yourself,
the HealthQuest Perks Program is made
up of negotiated discounts for services
with companies that can provide health
& wellness related services for members.
These companies include:
Weight Watchers: HealthPlus has joined
forces with Weight Watchers to bring
HealthPlus members special savings rates
and now of will reward its members
for participating! Simply complete 10
weeks of your Weight Watchers plan and
HealthPlus will reimburse 50% of your cost
(a maximum of $83)!
Jenny Craig: HealthPlus and Jenny Craig
have teamed up to assist you. HealthQuest
Perks now ofers a Jenny Craig discount
just for being a valued HealthPlus member.
Snap Fitness: HealthPlus members
can enjoy free enrollment plus 10% of
monthly dues at Snap Fitness Centers
nationwide.
Hurley Health & Fitness: Members can
take advantage of a $29 joining fee ($249
value) and half-of dues for the frst three
months. This ofer cannot be combined
with any other ofers.
EdgePark Medical Supplies:
HealthPlus has teamed up with EdgePark
Medical Supplies to ofer free diabetic
meters and great discounts on various
medical supplies such as scales, blood
pressure cufs and other supplies not
covered under your medical beneft.
Contact EdgePark for assistance.
Page 21 Health and Wellness
Asthma
Asthma is a common health problem that
causes swelling in your throat and lungs.
The swelling makes it harder to get air in
your lungs. Usually this swelling is due to
things like mold, pet dander, pollen, grass,
dust or weather changes. The swelling
can cause wheezing. It can also cause
shortness of breath or a cough which
does not go away, especially late at night
or early in the morning. Taking medicine
every day will help to prevent or decrease
the swelling. This makes breathing easier.
If you have asthma, there are ways you and
your doctor can work together to help you
live a normal, healthy life.
1. Measure your peak fow. Start by
taking a reading when you are not
having symptoms. This is a time when
your doctor can work with you to
develop an asthma action plan. The
action plan will tell you what to do
if your reading falls into one of three
zones: red, yellow or green. Green
means that you are doing great using
your daily routine. Yellow means to
be careful. You may need your rescue
inhaler. Red means that you should
contact your doctor right away.
2. Keep a diary of your readings and
sharing this with your doctor at each
visit
3. Adjust your medicine the way your
doctor tells you to
4. Be aware of things that can bring on
an asthma attack
5. Always carry a rescue inhaler with
you
Asthma classes may be covered by
HealthPlus Partners. Call HealthQuest toll-
free at 1-800-345-9956, ext. 1943, option 4
for details.
Diabetes
Diabetes is a chronic illness. When you
have diabetes, your body has trouble
breaking down sugars in the food you eat.
Diabetes can cause other problems like
heart disease, stroke and kidney disease.
It can also cause infections, blindness and
loss of limbs. Heres the good news! The
complications of diabetes can be reduced
or prevented if they are found early and
treated the right way.
The American Diabetes Association says
that everyone 45 and older should be
tested for diabetes. Talk to your doctor
about being tested if:
n Someone in your family has diabetes
n You are overweight
n You are of African American or
Hispanic descent
n You are experiencing increased thirst,
increased urination or unexplained
weight loss.
If you have diabetes, you should have
the following every year:
n Retinal eye exam by an eye care
specialist
n Regular blood tests to monitor your
blood sugar (A1c) and lipids (LDL
bad cholesterol and HDL good
cholesterol)
n Urine tests to measure the protein
and albumin in your urine, to see how
your kidneys are functioning
n Monitoring of your blood pressure
n Foot examinations
Disease Management
Heart Disease
Heart disease can happen when the blood
vessels that feed the heart get too narrow.
It can also be caused if the heart loses the
power to pump blood to the rest of the
body. This is called congestive heart failure.
Blocked or narrow arteries cause strokes
and heart attacks.
Men over the age of 45 and women over
the age of 55 are more likely to get heart
disease. You are also more likely to get
heart disease if you smoke or have high
blood pressure. High cholesterol makes it
more likely that you will get heart disease.
So does having a family history of people
with heart disease at an early age.
Some symptoms that could indicate heart
problems are:
n Swelling in your feet, legs or
abdomen
n Shortness of breath that wakes you
up at night
n A cough that gets worse or does not
go away
n Shortness of breath that gets better
when you sit up
Talk to your doctor if you have one or more
of these symptoms or risk factors. You
can lower your chances of getting heart
disease if you eat right and exercise. Some
people may need to take medicine to
improve the fow of blood to their heart.
Page 22 Disease Management
Miscellaneous
New Technology
We know that it is important to stay up to
date with what is available in health care.
Doctors help HealthPlus Partners evaluate
new medical technology by:
n Reviewing research about new
technology
n Reviewing the benefts of using the
technology
n Deciding if it should be included as a
beneft
If You Have Other Insurance
If you have other insurance, please let us
know. This helps us to coordinate your
services and make sure your bills are paid
timely. Call Customer Service at
1-800-332-9161.
If You Receive a Bill
You should never be asked to pay for any
authorized, covered service. There are no
copays except for the copays described
in the benefts section of this handbook.
If you receive a bill for an authorized,
covered service, please contact Customer
Service.
If You Move or Lose
Medicaid Eligibility
If you move outside of the service area,
you cannot be a HealthPlus Partners
member. You must notify the DHS ofce in
your new county.
If you lose your Medicaid eligibility with
the State, you cannot be a member of the
HealthPlus Partners program.
If you are unhappy with us, please let us
know. We will try to solve the problem.
If you would like to join a diferent plan,
you must call Michigan ENROLLS at
1-888-ENROLLS.
Request for Disenrollment
HealthPlus Partners may request your
disenrollment if:
1. You let someone else use your
HealthPlus Partners ID card for
services.
2. You cannot maintain a good
relationship with your doctor.
Examples of a bad relationship are:
Refusing to follow the doctors
advice
Continually going to an
emergency room for non-
emergency care
Going to a provider who is not
with HealthPlus Partners without
your doctors okay
3. If you commit acts of fraud.
4. If you make threats, life threatening
or otherwise.
We will talk to you when these things
happen. We will only ask that you be
disenrolled if we cant solve the problem.
If you do not agree with us, you may start
the Member Satisfaction process by calling
Customer Service at 1-800-332-9161.
Fraud, Waste and Abuse
HealthPlus Partners has a license to
do business as a health maintenance
organization (HMO). Laws regulate
the health care services provided by
HealthPlus Partners. HealthPlus Partners
members, employees and providers must
follow these laws. HealthPlus Partners
must report all fraud waste or abuse.
Fraud can mean lying to get a beneft that
is not in your contract. Abuse can mean
doing something that leads to extra costs
for HealthPlus Partners. It also means
paying doctors for services that:
n Arent medically necessary
n Dont meet the standard of care
To report fraud, waste or abuse, call the
confdential Compliance Hotline at
1-888-706-1504. You also can write to:
Theresa M. Schurman, Esq.
Compliance Ofcial
2050 S. Linden Road
Flint, MI 48532
Or visit our website at www.healthplus.org.
You also can call the Department of
Community Health Ofce of Health
Services Inspector General (OHSIG) at
1-855-643-7283 or online at www.
michigan.gov/fraud. You can also write to
them at:
Ofce of Health Services Inspector General
P.O. Box 30479
Lansing, MI 48909
You do not have to give your name
.
Examples of fraud, waste or abuse
by a member include the following:
n Changing a prescription
n Changing medical records
n Changing referral forms
n letting someone else use your
HealthPlus Partners insurance card to
get medical services
n Using transportation services to
do something other than go to the
doctor or pharmacy
Page 23 Miscellaneous
Examples of fraud, waste or abuse
by a provider include the following:
n Lying about credentials such as a
college degree
n Billing for services that werent done
n Billing a balance that isnt allowed
n Double billing, upcoding and
unbundling
n Collusion among providers
providers agreeing on minimum fees
they will charge and accept
n Underutilization not ordering
services that are medically necessary
Examples of fraud, waste or abuse
by an employee of HealthPlus
Partners include the following:
n Lying about a providers credentials
or provider network
n Forging a signature on a contract
n Pre- or post-dating a contract
n Intentionally submitting false claims
n Rigging bids collusion between
state employees and HMO
employees
n Self-dealing awarding a contract
based solely on friendship or family
relationships
n Embezzlement or theft
n Excessive salaries and fees to close
associates of HealthPlus Partners
Member Satisfaction Plan
We want you to be happy as a member. If
you have a question or problem, call us at
1-800-332-9161. We will try to answer your
question on the phone. If not, we will try
to solve the problem within two days. If
you are not happy with the results or with
any decision made by HealthPlus Partners,
you or someone you choose to help you
can fle a grievance. We will assist you in
fling the grievance if needed. Start by
contacting us:
Call us at 1-800-332-9161 or,
Send a letter to:
HealthPlus Partners
2050 S. Linden Rd.
Flint, MI 48532 or,
Fax a letter to (810) 733-1947 or,
come to our ofces for a meeting.
There are Two Stages of
Grievances
Stage One
1. Contact us within ninety (90) days
following the date of notice of
adverse determination.
2. We will contact you within ffteen (15)
calendar days after receiving your call
or letter.
3. At that time, we will let you know
about any information we have
and anything that we have done to
address the problem.
4. If you are not happy with our answer,
you can appeal or ask that we take
another look at the problem. That
leads you to Stage Two.
Stage Two
1. Let us know within fve (5) calendar
days following the Stage One
decision that you want another
review.
2. We will have a meeting with the
Grievance Appeal Committee within
thirteen (13) calendar days after
hearing from you.
3. You may speak to this Committee or
have someone speak on your behalf.
If you cannot be at the meeting, you
can join us by phone.
4. We will let you know the Committees
fnal decision within two (2) calendar
days of the meeting.
5. If you are not happy, you have
the right to appeal to the State of
Michigan, Department of Insurance
and Financial Services (DIFS). This is
the External Review.
External Review
If you are still not pleased or if we have not
contacted you within ffteen (15) calendar
days from fling your grievance under
Stage Two, you can appeal by writing or
calling:
Department of Insurance and
Financial Services
Division of Insurance
Health Plans Division
611 Ottawa, Second Floor
PO Box 30220, Lansing, MI 48909-7720
(517) 335-2057 or
1-877-999-6442 (toll free)
If you ask for an external review, you have
given us permission to share your health
information including the medical record,
if needed, for the review.
If we have made an adverse determination
- meaning we reduced, denied or ended
a service - you must ask for the external
review within sixty (60) calendar days
of being told of having your grievance
denied.
If your request for a review is approved,
DIFS will either review your case or have
an Independent Review Group (IRO)
review your case. Both you and HealthPlus
Partners may give this group any
information about your case.
This group will make a recommendation
to DIFS within fourteen (14) calendar days.
DIFS then has seven (7) working days to
make a fnal decision.
If your request for review does not involve
an adverse determination, DIFS may assign
staf to review your case. Within fourteen
(14) calendar days, a recommendation will
be made.
Page 24 Miscellaneous
Miscellaneous
Expedited
An expedited grievance can be requested
if you believe that following the HealthPlus
Partners normal time frames would
seriously harm your health or life. You
may request this or you may give written
approval for someone else to act on your
behalf. You can only ask for an expedited
process if we have denied a request for
services before you receive the service.
We will decide if the facts about your issue
need to be addressed by this process.
If not, we will use the normal process.
We will inform you of the decision about
your grievance within seventy-two (72)
hours after we receive it. You and your
doctor will receive the decision in writing
within two (2) calendar days of any oral
decision.
If you are not satisfed with our decision,
you can fle an appeal within ten (10)
calendar days.
Expedited External Review
If your doctor believes that following the
time frames in our expedited process
would seriously harm your health or
life and you have asked us to follow the
expedited process, you may request an
expedited external review from DIFS.
DIFS may decide to send this to the review
group. This group may decide that you do
not have to wait for us to make a decision.
If so, they will review your case and make
a recommendation within thirty-six (36)
hours. You will be notifed within twenty-
four (24) hours of the completed
review, of DIFSs decision.
State Fair Hearing Process
You have the right to fle a complaint with
the State before or at the same time as
fling one with HealthPlus Partners.
You must request a hearing within 90 days
of the initial denial decision. However,
we hope that you will give us a chance to
resolve the problem. If you decide to fle
with the State, follow these fve stages:
1. Call 1-800-642-3195 for a Hearing
Request Form.
2. Return the completed form to the
address listed on the form.
3. A worker from the State will contact
you and try to solve the problem
before a hearing is scheduled.
4. If the problem cannot be fxed, the
State will send you a letter telling
you when the hearing will be held.
5. The decision from the hearing will be
sent to you within ten (10) days after
the hearing is held. If the problem
is fxed before the hearing date,
you may call and ask for a Hearing
Request Withdrawal Form.
Member Rights and
Responsibilities
You have the right:
1. To be treated with respect and
dignity and with regard for your
privacy.
2. To receive quick and friendly service.
3. To receive information about the
health plan, the providers that
give you care and your rights and
responsibilities.
4. To complain or fle a grievance about
HealthPlus Partners or services that
you receive. To get a response to that
complaint or grievance.
5. To change PCPs for any reason.
6. To help make decisions about your
medical care.
7. To discuss treatment options
without regard to cost or beneft
coverage.
8. To refuse treatment and be told of
the possible impact of doing so.
9. To confdential health records except
when disclosure is required by law or
approved in writing by you.
10. To review your medical record with
your PCP.
11. To make recommendations about
the HealthPlus Partners member
rights and responsibilities.
12. To get medical care regardless of
race, color, religion, sex, sexual
orientation, age, disability, national
origin, veterans status and stay,
health status or need for health
services.
You have the responsibility:
1. To treat HealthPlus Partners
providers and staf with respect.
2. To choose a PCP and to keep
appointments or cancel when
necessary.
3. To be honest when providing
information to treatment staf.
4. To follow the advice of the treatment
staf and to consider the impact if
you refuse to listen.
5. To express your complaints to the
appropriate people at HealthPlus
Partners or to your doctor.
Page 25 Miscellaneous
6. To notify HealthPlus Partners and
your case worker of a change in your
phone number, address and the
number of people in your family.
7. To understand your health problems
and to work together with your
doctor to develop treatment plans.
8. To provide the information
HealthPlus Partners and your doctor
need to give you care.
HealthPlus Partners will ensure that
employees and providers will comply with
all requirements concerning your rights as
a patient.
Patient Bill of Rights
We believe that you should know about
your health plan. A Michigan law called
the Patient Bill of Rights wants you to
know the following:
Page 26 Miscellaneous
Service Area
The service area is: Bay, Genesee,
Lapeer, Saginaw, Shiawassee and Tuscola
Counties.
Subscriber Contract
The contract will explain your benefts,
including:
n emergency services
n out of area services
n how to fle a grievance
n all health services, including
pharmacy
n any out of pocket expenses you may
have
Continuity of Treatment
What happens if your providers contract
ends during your course of treatment?
HealthPlus Partners will arrange for
continued treatment or will help you fnd a
new provider.
Intractable Pain
Intractable pain is when the cause of the
pain cannot be removed or treated. If you
believe that you may have this pain, you
should talk to your PCP.
Your PCP will examine you and treat
you. He may refer you to a specialist if
necessary.
Additional Information
You have the right to receive the following:
1. A provider directory which includes
names of providers, hospitals and
how to change doctors.
2. Information about the credentials
of our doctors including degrees,
hospital privileges and certifcation
date.
3. The process to fnd out about any
discipline regarding your doctor.
4. Information about any requirements,
limitations or exclusions on your
benefts, including information about
our recommended list of drugs.
5. Summary information about the
fnancial arrangements between
HealthPlus Partners and any provider.
This includes how the provider is
paid and if the payment is based on
quality or patient satisfaction.
Who to Contact
If you would like any of this information,
call Customer Service at 1-800-332-9161.
You have the right to make your own
decisions about your medical care. You
also have the right to plan and direct the
types of health care you may receive if you
become unable to express your wishes.
This is called an Advanced Directive.
As a competent adult, you have the
right to accept or refuse any treatment.
Competent means you understand your
medical condition and the treatment for
it. You can review the pros and cons of
each treatment, then decide to accept it or
refuse it.
Miscellaneous
Your Right to Make Medical Care
DecisionsAdvanced Directives
You also have the right to make your
own decisions about your medical care.
You also have the right to plan and
direct the types of health care you may
receive if you become unable to express
your wishes. This is called an advanced
directive. As a competent adult, you have
the right to accept or refuse any treatment.
Competent means you understand your
medical condition and the treatment for
it. You can review the pros and cons of
each treatment, then decide to accept it or
refuse it.
Who decides what treatment
I should get?
You make the decisions as long as you are
competent. You can say yes or no to any
treatment ofered. You can say no even
if the treatment would keep you alive
longer. You can say no even if others want
you to have it.
What if I am in no condition to
decide?
If you become unable to make your own
decisions about medical treatment and
you have not told anyone what to do,
someone else like your family or the courts
may have to decide for you.
What can I do now to see that my
wishes are met?
While you are competent, you can name
someone to make your medical decisions
for you, in case you are unable to make
them yourself. The person you name has
the legal right to make those decisions.
This person is called a Patient Advocate.
Who can be a Patient Advocate?
The person must be at least 18 years old.
You can pick a family member or friend.
Make sure that the person is willing to
help you by signing a form. Its a good
idea to have a back up person in case the
frst person is unable to act when the time
comes.
Where do I get the Patient Advocate
Designation Form?
You can get a form from many places,
including hospitals, nursing homes,
churches and lawyers. There are diferent
kinds, so pick the one that is best for you.
How do I sign the form so that it is
valid?
You must fll in the name of the advocate
and sign the form in front of two
witnesses. Under the law, your spouse,
parents, children, grandchildren, and
brothers and sisters cannot witness your
signature. Neither can anyone else who
could be named to get something in
your will, could be your heir or works for a
company that insures your life or health.
Other people who cannot act as a witness
include the person named as the Patient
Advocate, your doctors and any employee
of the facility providing your treatment.
It is easier to name a Patient Advocate
before you become ill. Friends are often
good people to ask to be a witness.
They can swear that you were of sound
mind and signed the form voluntarily.
What do I do with the forms after I
fll them out?
You should give copies of the form to your
PCP or hospital so that it can be placed in
your medical record. Tell your family and
friends that you have completed the form
and think about giving them a copy.
Do I have to give my Patient
Advocate instructions?
No. The form is used to name your Patient
Advocate. But it will be helpful to write
down instructions so that the advocate
does exactly what you want.
If you want your advocate to be able to
refuse treatment and to let you die, you
must write that on the Patient Advocate
Designation Form.
Can I just give instructions and not
name a Patient Advocate?
Yes. You can tell your family and close
friends what your wishes are. You can
also write a Living Will. This is a written
statement of your choices about medical
treatment. Those taking care of you will
feel more confdent that they know what
you would have wanted.
Do I have to make a decision now
about my future medical treatment?
No. You will still get the medical treatment
you choose now. If you become unable to
make decisions, make sure that your family
and friends know what you want. Without
instructions from you, a court may have to
decide your treatment if your family and
providers cannot agree.
If I make decisions now, can I change
my mind later?
Yes. You can give new instructions in
writing or tell your family. You can also
change your mind about naming a
Patient Advocate at all and cancel the
form.
You should read your Patient Advocate
Form or Living Will at least once a year.
Make sure that it still states how you want
to be treated and names the person you
want to make the decisions for you.
What else should I think about?
Treatment decisions are hard. You should
think about them in advance and discuss
them with your family. You should ask your
provider or hospital about their treatment
policies to be sure that you understand
them.
If you fnd that your advanced directives
were not honored by a health care
provider, you may fle a complaint with the
State of Michigan.
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
fle a complaint).
For complaints about how your health
plan follows your wishes, write or call:
Ofce of Financial and Insurance
Regulation
Division of Insurance
Health Plans Division
611 Ottawa, Second Floor
P.O. Box 30220
Lansing, MI 48909-7720
Toll free at 1-877-999-6442
or www.michigan.gov/difs
Medical Decisions/Advanced Directives
Page 27 Medical Decisions/Advanced Directives
Privacy Notice
Efective as of April 14, 2003
This notice describes how personal and medical
information about you may be used and disclosed
and how you can get access to this information.
Please review it carefully.
Information We Have.
We receive enrollment information about you,
which includes your date of birth, sex, identifcation
number, and other personal information including
social security numbers. We also receive bills,
physician reports and other information about your
medical care. For some health insurance programs,
HealthPlus may have credit card and/or bank account
information which is supplied by you for payment of
premiums.
Our Privacy Policy.
We care about your privacy and we guard your
information carefully. We are required to maintain
the privacy of your information and to provide you
with this notice of our legal duties and our privacy
practices. Internally, we protect your oral, written
and electronic information by requiring employees
and others with access to such information to
follow specifc confdentiality and technology use
procedures. We maintain physical safeguards such
as shredding documents and securing buildings;
electronic safeguards, such as encryption and
monitoring; and procedural safeguards, such as
customer authentication procedures, to guard your
information against unauthorized access or use. We
will not sell any information about you. Only people
who have both the need and the legal right may
see your information. Unless you give us a written
authorization, we will only disclose your information
for purposes of treatment, payment, business
operations or when we are required by law to do so.
Treatment.
We may disclose medical information about you for
the purpose of coordinating your health care. For
example, we may notify your personal doctor about
treatment you receive in an emergency room.
Payment.
We may use and disclose medical information about
you so that the medical services you receive can be
properly billed and paid. For example, we may ask
a hospital emergency department for details about
your treatment before we pay the bill for your care.
Business Operations.
We may need to use and disclose medical
information about you in connection with our
business operations with afliated entities. For
example, we may use medical information about you
to review the quality of services you receive and to
investigate fraud and abuse.
Health-Related Benefts and Services.
We, or our agents, may contact you about other
health-related benefts and services that may be of
interest to you.
As Required By Law.
We will release information about you when we are
required by law to do so. Examples of such releases
would be for law enforcement or national security
purposes, subpoenas or other court orders, public
health services, communicable disease reporting,
disaster relief, review of our activities by government
agencies, to avert a serious threat to health or safety
or in other kinds of emergencies.
Employer Plans.
We will share only enrollment information or
summary health information (or other information if
required by law) with an employer or plan sponsor.
However, we may share your personal and medical
information with the employer or plan sponsor if
you are a participant or dependent in a self-funded
employer health plan and the employer has provided
us with written assurances that the information
will be kept confdential and will not be used for an
improper purpose.
Authorizations.
If you give us a written authorization to do so, we may
use and disclose your personal information. If you
give us a written authorization, you have the right to
change your mind and revoke that authorization.
Copies of this Notice.
You have the right to receive an additional copy of
this notice at any time. Even if you have agreed to
receive this notice electronically, you are still entitled
to a paper copy of this notice. Please call or write to us
to request a copy.
Changes to this Notice.
We reserve the right to revise the Privacy Notice.
A revised notice will be efective for medical
information we already have about you as well as
any information we may receive in the future. We are
required by law to comply with whatever notice is
currently in efect. Any changes to our notice will be
published in our member newsletter.
Other Laws and Regulations.
HealthPlus must comply with all federal and state
laws and regulations. Michigan law and other federal
law may provide additional protection for your
personal health information (e.g., social security
numbers, HIV/AIDS, behavioral health, and minors).
Your Right to Inspect and Copy.
Upon written request, you have the right to inspect
the information we have about you and to get copies
of that information.
Your Right to Amend.
If you feel that the information about you, which
we have, is incorrect or incomplete, you can make a
written request to us to amend that information. We
can deny your request for certain limited reasons, but
we must give you a written reason for our denial.
Your Right to a List of Disclosures.
Upon written request, you have the right to receive
a list of our disclosures of your information, except
when you have authorized those disclosures or if
the disclosures are made for treatment, payment, or
health care operations. We are not required to give
you a list of disclosures made before April 14, 2003.
Your Right to Request Restrictions on Our Use or
Disclosure of Information.
If you do so in writing, you have the right to request
restrictions on the information we may use or
disclose about you. We are not required to agree to
such requests.
Your Right to Request Confdential
Communications.
You have the right to request that we communicate
with you about medical matters in a certain way or
at a certain location. Your request must be in writing.
For example, you can ask that we contact you only at
home or only at a certain address or only by mail.
How to Use Your Rights Under This Notice.
If you want to use your rights under this notice, you
may call us or write to us. If your request to us must
be in writing, we will help you prepare your written
request, if you wish.
Complaints and Communications to Us.
If you want to exercise your right under this Notice or if
you wish to communicate with us about privacy issues
or if you wish to fle a complaint, you can write to:
Compliance & Privacy/Security Ofcial
2050 S. Linden Road
Flint, Michigan, 48532
Or call the compliance hotline at 1-800-345-9956.
You will not be penalized for fling a complaint.
Complaints to the Federal Government.
If you believe that your privacy rights have been
violated, you have the right to fle a complaint with
the federal government. You may write to:
Ofce of the Secretary
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
You will not be penalized for fling a complaint with the
federal government.
Explanation of Benefts
(EOB)
Efective January 2010, HealthPlus Partners will
begin to send out Explanation of Benefts (EOB) to a
random sample of 5% of its members.
This is a new requirement by the Michigan
Department of Community Health (MDCH).
HealthPlus Partners will send EOBs quarterly.
You may receive an EOB from time to time. The
EOB shows the claims HealthPlus has paid on your
behalf for that quarter. Services that are protected
classes will not be included. If you did not receive
the services listed, please contact our confdential
compliance hotline at 1-800-345-9956. You do not
have to leave your name. You may also go to our
website at www.healthplus.org or write to:
Theresa Schurman, Esq.,
Compliance Ofcial
2050 S. Linden Rd., Flint, MI 48532
Or you may call or write:
Department of Community Health Medicaid
Integrity Program
Michigan Department of Community Health
Medicaid Integrity Program
Capitol Commons Center Building
400 S. Pine St., 6th Floor
Lansing, MI 48909
Toll-Free 1-866-428-0005
Page 28 Privacy Notice
HealthPlus Partners Subscriber Contract
SECTION I
INTRODUCTION
This Contract is between HealthPlus Partners, Inc., (HPP) a
nonproft Michigan corporation, operating a state-licensed health
maintenance organization and the Eligible Individual (and any
Eligible Dependent, if applicable) who enrolls with HPP in order to
receive Health Care Benefts. By enrolling with HPP, accepting this
Contract, and using the HPP Identifcation Card, Eligible Individual
(and any Eligible Dependent(s), if applicable) agree(s) to be bound
by the terms and conditions of this Contract. Under this Contract,
Covered Services must be provided by Afliated Providers unless
otherwise indicated.
SECTION II
DEFINITIONS
THE FOLLOWING DEFINITIONS SHALL
APPLY TO THE CONTRACT:
2.1 Act means Public Act 368 of 1978, Michigan Public
Health Code, as amended.
2.2 Acute Care Service means the provision of highly con-
centrated care to patients requiring comprehensive ob-
servation, continuous monitoring, and treatment with
immediate Physician intervention when necessary due
to the seriousness or unstable nature of the illness or
injury.
2.3 Adverse Determination shall mean an HPP determina-
tion that an admission, availability of care, continued
stay, or other health care service (including the type
or level of service) or beneft has been reviewed and
denied, reduced or terminated. Failure to respond in a
timely manner to a request for a determination consti-
tutes an Adverse Determination. Whenever an Adverse
Determination is made, a written statement containing
the reasons for the Adverse Determination will be pro-
vided to the Member (or his or her Authorized Repre-
sentative) along with any written notifcations that may
be required by state or federal law.
2.4 Afliated means, as it relates to a Hospital, Physician,
or other Provider, any such a Provider who has agreed in
writing to provide services to Members.
2.5 Application means those documents each person
must complete in order to become an Eligible Individu-
al.
2.6 Appropriately Referred means that situation when a
referral is issued on behalf of a Member from that Mem-
bers Primary Care Physician to another Provider, or from
a Physician to whom a Member is referred to another
Provider, if such referrals are consistent with HPPs refer-
ral policy.
2.7 Authorized Representative shall mean any of the fol-
lowing:
A. a person to whom a Member has given express
written consent, including a Practitioner, to repre-
sent him/her in a Grievance or an external review;
B. a person authorized by law to provide substituted
consent for a Member; or
C. for Urgent Care Claims or if the Member is unable to
provide consent, a family member of the Member
or the Members treating health care professional.
2.8 Basic Care means the provision of care to persons who
may have need of assistance with the activities of daily
living, visual observation of patient individual needs,
maintenance of a hazard free environment, and the pro-
vision of dietary, social and emergency services.
2.9 Chiropractor means an individual licensed under the
Act or other similar licensing statute or law of the appli-
cable governing state or governmental unit to engage
in the practice of chiropractic medicine
2.10 Claim shall mean any request for benefts made by a
Member, or his or her Authorized Representative, that
complies with HPPs procedures for making beneft
claims. Claims include Pre-Service Claims, Post-Service
Claims, and Urgent Care Claims.
2.11 Concurrent Care Decisions shall mean decisions afect-
ing an ongoing course of treatment taking place over a
period of time or a number of treatments.
2.12 Contract means the Application, the Identifcation
Card, this document and any other document issued by
Group or HPP which is necessary for the administration
of benefts.
2.13 Copayment means the amount each Member must
pay per visit to a treating Provider or Pharmacy in con-
nection with Health Care Benefts.
2.14 Cosmetic means to improve appearance or self-per-
ception.
2.15 Covered Services mean a service(s) for which Health
Care Benefts are available under this Contract.
2.16 Dental Care means services or procedures which con-
cern maintenance or repair of the teeth and/or gums or
are performed to prepare the mouth for dentures.
2.17 Dentist means an individual licensed under the Act or
any licensing statute or law of the applicable governing
state or governmental unit to engage in the practice of
dentistry.
2.18 DIFS means Department of Insurance and Financial
Services.
2.19 Dual Eligible means an individual covered under both
Medicare and Medicaid
HEALTHPLUS PARTNERS SUBSCRIBER CONTRACT
Page 2 9
HealthPlus Partners Subscriber Contract
2.20 Durable Medical Equipment means equipment of the
type approved by HPP which is able to withstand re-
peated use, is primarily and customarily used to serve a
medical purpose, and is not generally useful to a person
in the absence of illness or injury.
2.21 Eligible Dependent means a dependent of an Eligible
Individual who is determined to be eligible for member-
ship in HPP by the Michigan Department of Community
Health or its designee.
2.22 Eligible Individual means an individual who is de-
termined to be eligible for membership in HPP by the
Michigan Department of Community Health or its des-
ignee.
2.23 Emergency Health Service means Medically Necessary
services rendered by Providers for the sudden onset of
a medical condition that manifests itself by signs and
symptoms of sufcient severity, including severe pain,
such that the absence of immediate medical attention
could reasonably be expected to result in serious jeop-
ardy to the individuals health or to a pregnancy in the
case of a pregnant woman, serious impairment to bodi-
ly functions, or serious dysfunction of any bodily organ
or part.
2.24 Expedited Grievance shall mean a Grievance for Ur-
gent Care Claims.
2.25 Experimental means that a service is of doubtful
medical usefulness or efectiveness to the Member, as
assessed by local medical community standards. The
fnal determination of experimental procedures shall be
made by HPP.
2.26 Freestanding Emergency Center means a facility
which is licensed, certifed, or otherwise authorized pur-
suant to the Act or any similar licensing statute or law
of its governing state or governmental unit to provide
services in emergencies or after hours.
2.27 Grievance shall mean a dispute on behalf of a Member,
presented (orally or in writing) by the Member or his/
her Authorized Representative including a Practitioner
regarding:
A. the availability, delivery, or quality of health care
services (including an Adverse Determination con-
cerning utilization review);
B. Pre-Service Claims or Post-Service Claims; benefts
or claims payment, handling or reimbursement for
health care services;
C. the reduction, suspension, or termination of a previ-
ously authorized service;
D. the failure to provide services in a timely manner, as
defned by the State;
E. the failure of HPP to act within the established time-
frames for Grievance and appeal disposition;
F. for a resident of a rural area with only one Medic-
aid Health Plan, the denial of a Members request
to exercise his or her right, under 42 CFR 438.52(b)
(2)(ii), to obtain services outside HPPs network of
Afliated Providers;
G. matters pertaining to the contractual relationship
between a Member and HPP;
H. the denial or limited authorization of a requested
service, including the type or level of service; or
I. the denial in whole or in part, of a payment for a
properly authorized and Covered Service.
2.28 Grievance Appeal means the second level of the Griev-
ance process.
2.29 Group means the legal entity which has contracted
with HPP for Health Care Benefts for Eligible Individuals
and Eligible Dependents. Under this Contract, the legal
entity is the State of Michigan, for and on behalf of the
Michigan Department of Community Health.
2.30 Health Care Benefts mean the benefts provided by
this Contract for health care services rendered to Mem-
bers.
2.31 Hearing Aid means an electronic device of the type
approved by HPP worn on the person for the purpose of
amplifying sound and assisting the physiologic process
of hearing, and includes an ear mold, if Medically Neces-
sary.
2.32 Home Health Agency means a facility or program
which is licensed, certifed, or otherwise authorized pur-
suant to the Act or other similar licensing statute of its
governing state or governmental unit and is approved
to provide home health services.
2.33 Hospice means a Provider which is licensed, certifed,
or otherwise authorized pursuant to the Act or other
similar licensing statute of its governing state or gov-
ernmental unit to supply pain relief, symptom manage-
ment, and supportive services to individuals sufering
from a disease or condition with a terminal prognosis.
2.34 Hospital means a facility ofering inpatient, overnight
care, and services for observation, diagnosis, and active
treatment of an individual with a medical, surgical, ob-
stetric, chronic, or rehabilitative condition requiring the
daily direction or supervision of a Physician. Hospital
does not include a mental health hospital licensed or
operated by the Department of Community Health or a
hospital operated by the Department of Corrections.
2.35 HPP means HealthPlus Partners, Inc., a nonproft Mich-
igan corporation with its principal ofce located at 2050
South Linden Road, Flint, Michigan 48532.
2.36 HPP Medicaid Formulary means a list of selected or
preferred drug products and supplies available to a
Member pursuant to relevant HPP organizational poli-
cies and procedures.
2.37 Identifcation Card means the card issued to an Eligi-
ble Individual by HPP.
2.38 Intermittent Skilled Nursing Care means services pro-
vided by a licensed nurse to a Member who has a medi-
cally predictable recurring need for Skilled Care at least
once in every sixty (60) day period.
2.39 IRO means Independent Review Organization.
2.40 Medically Necessary means services or supplies pro-
Page30
HealthPlus Partners Subscriber Contract
vided to Members that are medically required and ap-
propriate to diagnose and treat a Members physical or
mental condition. Also, such services or supplies must:
(1) meet widely accepted criteria and professionally rec-
ognized standards of health care; (2) not be used pri-
marily for the comfort or convenience of the Member,
the Members family or caregiver, or the Members treat-
ing Physician; (3) not be excessive in cost as compared
to alternative services or supplies for the diagnosis or
treatment of the Members physical or mental condi-
tion; and (4) not be provided to the Member as an inpa-
tient when the services or supplies could be safely and
appropriately provided to a Member on an outpatient
basis.
2.41 Medicaid Program means the program administered
by the Michigan Department of Community Health to
provide for medical assistance established by Section
105 of Act No. 280 of the Public Acts of 1939, as amend-
ed, and Title XIX of the Social Security Act, as amended.
2.42 Medicare means Title XVIII of the Social Security Act
and all amendments thereto.
2.43 Member means the Eligible Individual and his/her Eli-
gible Dependents covered under this Contract.
2.44 Michigan Department of Community Health means
the state agency responsible for administering the Med-
icaid Program.
2.45 Non-Afliated or Non-Plan means, as it relates to a
Hospital, Physician, or other Provider, any such Provider
who has not agreed in writing to provide services to
Members.
2.46 Orthotic Appliance means an apparatus of the type
approved by HPP which is used to support, align, pre-
vent, or correct deformities, or to improve the function
of movable parts of the body.
2.47 Outpatient Mental Health means therapeutic services
which last less than four (4) consecutive hours.
2.48 Personal Health Information includes medical informa-
tion (i.e., claims, referrals, health assessments, etc.) and
other administrative data (i.e., names, addresses, social
security numbers, etc.) that are personally identifable.
2.49 Pharmacy means a business licensed under the Act or
similar licensing statute or law of its governing state or
governmental unit to engage in the practice of phar-
macy.
2.50 Physician means an individual licensed under the Act
or other similar licensing statute or law of the applicable
governing state or governmental unit to engage in the
practice of allopathic or osteopathic medicine and sur-
gery.
2.51 Plan Physician means any Physician who has entered
into a written contract to provide services to Members.
2.52 Podiatrist means an individual licensed under the Act
or other similar licensing statute or law of the applicable
governing state or governmental unit to engage in the
practice of podiatric medicine.
2.53 Preferred Mental Health Provider means an Afliated
Provider specializing in the treatment of mental illness
who is both selected by a Member for his/her care and
is designated by HPP as a Preferred Mental Health Pro-
vider.
2.54 Prescription Drug means any medicinal substance
listed in the HPP Medicaid Formulary that is approved
by HPP and the original packaging of which, under
the Federal Food, Drug, and Cosmetic Act, is required
to bear the legend, Caution: Federal Law prohibits dis-
pensing without a prescription, or which is designated
by the State Board of Pharmacy as one which may only
be dispensed pursuant to a prescription for the Mem-
bers personal use.
2.55 Pre-Service Claim shall mean any Claim that, under the
terms of the Members Subscriber Contract, must be ap-
proved (either in whole or in part) before medical care is
obtained.
2.56 Post-Service Claim shall mean any Claim that is not a
Pre-Service Claim.
2.57 Practitioner means a licensed professional who pro-
vides health care services.
2.58 Prevalent Language means a non-English language
spoken by a signifcant number or percentage of Mem-
bers or potential Members in the state.
2.59 Primary Care Physician means a Plan Physician who is
both selected by a Member or assigned by the Plan to
provide his/her care and is designated and recorded by
HPP as providing primary care services.
2.60 Prosthetic Device means a device of the type ap-
proved by HPP that replaces all or a part of an internal
body organ or external body member, or that replaces
all or a part of the function of a permanently inoperative
or malfunctioning internal body organ or external body
member.
2.61 Provider means a health professional, facility, or agen-
cy complying with the Act or other similar licensing stat-
ute of the applicable governing state or governmental
unit.
2.62 Reasonable Charge means the lesser of the treating
Providers charge or the amount determined to be a fair
charge by HPP in comparison to charges of other Pro-
viders in the same geographic region.
2.63 Reconstructive means to efect a substantial improve-
ment or restoration of bodily function or to correct de-
formities resulting from disease, injury, or congenital or
developmental abnormalities.
2.64 Reside means the physical presence of a Member at a
particular address.
2.65 Semi-Private Room means a room containing two (2)
or more patient beds in an inpatient facility.
2.66 Service Area means the geographic area in which HPP
is authorized by regulating agencies to provide Health
Care Benefts to Members.
2.67 Short-Term means service for a condition which HPP
Page 31
HealthPlus Partners Subscriber Contract
determines can be expected to signifcantly improve
within a period of sixty (60) days.
2.68 Skilled Care means concentrated observation, moni-
toring, evaluation, and intervention by licensed and
trained personnel under the direction of a Physician
and usually does not require daily intervention for con-
ditions that are stable or stabilizing.
2.69 Skilled Nursing Facility means a facility licensed to
provide Skilled Care in accordance with the Act or other
similar licensing statute of its governing state or gov-
ernmental unit.
2.70 Specialist Physician means a Plan or Non-Plan Physi-
cian to whom a Member is Appropriately Referred.
2.71 Urgent Care Claim shall mean a Claim that, due to the
medical status of the Member, resolution within HPPs
normal time frames would seriously jeopardize the life
or health or ability to regain maximum function of a
Member or subject a Member to severe pain that can-
not be managed adequately. Only Pre-Service Claims,
and not Post-Service Claims, can be Urgent Care Claims.
2.72 Visit means a meeting between a Member and Provid-
er for the purpose of rendering Covered Services, with-
out regard to the frequency of meetings if each such
meeting is separated by any period of time.
SECTION III
ELIGIBILITY, ENROLLMENT,
AND EFFECTIVE DATE
3.1 ELIGIBILITY
A. Eligible Individuals. To be eligible to enroll as an Eli-
gible Individual, a person must:
1. be an Eligible Individual according to the eligi-
bility requirements for the Medicaid Program as
set forth by the Michigan Department of Com-
munity Health or its designee;
2. Reside in the Service Area;
3. complete the enrollment process as defned
by the Michigan Department of Community
Health or its designee; and
4. meet any other specifc eligibility criteria speci-
fed by HPP or the Michigan Department of
Community Health or its designee.
B. Eligible Dependents. To be covered as an Eligible
Dependent a person must be determined to be eli-
gible for membership in HPP by the Michigan De-
partment of Community Health or its designee.
3.2 INELIGIBILITY
A. If a Member covered under this Contract loses his/
her eligibility under the Medicaid Program, he/she
is no longer eligible for Health Care Benefts under
this Contract.
B. In all cases, fnal determination of eligibility will be
determined by the Michigan Department of Com-
munity Health or its designee.
3.3 ENROLLMENT AND EFFECTIVE DATE OF COVERAGE
A. Eligible Individuals and Eligible Dependents may
enroll by completing the enrollment process at the
times specifed by the Michigan Department of
Community Health or its designee.
B. Newborn children are automatically covered for the
month of their birth as long as the mother is Medic-
aid eligible at the time of the birth, covered by HPP,
and does not enroll the children in Childrens Spe-
cial Health Care Services (CSHCS).
C. All eligible, enrolled Members will be covered under
this Contract on the date agreed upon between the
Michigan Department of Community Health and
HPP, which date shall be referred to as the Efective
Date of Coverage.
D. A Member will be notifed in writing by HPP of the
Efective Date of Coverage.
E. A Member is not eligible for services under this Con-
tract until the Efective Date of Coverage.

SECTION IV
COORDINATION OF BENEFITS AND
SUBROGATION
4.1 COORDINATION OF BENEFITS
A. If a Member entitled to Health Care Benefts un-
der this Contract is also entitled to benefts under
any other private or public health beneft plan or
insurance policy, including automobile insurance,
benefts shall not be available under this Contract,
whether a claim is made for same, until the benefts
of the other health beneft plan or insurance policy
are exhausted. However, HPP will coordinate ben-
efts with other health beneft plans or insurance in
accordance with the Michigan Coordination of Ben-
efts Act (Public Act No. 64 of 1984, as amended) or
any other applicable and controlling law.
B. In no event shall any Member through coordination
of two (2) or more health plans or insurance policies
recover more than the actual or reasonable expens-
es for all services provided to that Member.
4.2 SUBROGATION
If a Member receives benefts from HPP under any of
the following circumstances, HPP will hold a lien against
and be otherwise subrogated to the rights of the Mem-
ber (or legal representative) to the extent of benefts
paid by HPP:
A. Services for which benefts are available under any
other public or private health plan or insurance (in-
cluding but not limited to automobile, home-own-
ers, or business insurance) for which HPP is not the
primary carrier under applicable law; or
B. Damages or injuries caused by or attributed to the
willful or negligent act or omission of any third par-
ty for which the Member receives (or could receive)
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HealthPlus Partners Subscriber Contract
payment.
4.3 MEMBER CONSENT
Accepting Health Care Benefts from HPP automatically
assigns to it any rights a Member has to recover pay-
ment from a third party. Member consents to the release
to and from HPP or its designee of all claims and other
information necessary to exercise HPPs coordination
and subrogation rights and agrees to execute all docu-
ments necessary for HPP to exercise said rights. Member
agrees to take no action legal or otherwise which would
lessen or diminish HPPs coordination and subrogation
rights.
Member consents to HPP bringing suit against any third
party to protect HPPs subrogation rights. HPPs subro-
gation rights and rights of recovery are asserted against
any money collected by a Member by operation of any
legal suit, settlement, or otherwise and requires that
HPP be fully reimbursed for Health Care Benefts it has
paid on the Members behalf whether or not the amount
he or she recovers compensates him or her in full for
the entire amount of his or her claimed loss. HPP may
assert its lien against the total amount recovered, and
is entitled to repayment in full, to the extent of Health
Care Benefts paid by HPP, prior to release of recovered
funds to any other party, without any ofset or reduction
for attorneys fees and costs. However, when reasonable
legal expenses are incurred in the recovery of monies,
an equitable division of expenses may be made at the
direction of HPP.
SECTION V
MEMBERS RIGHTS AND RESPONSIBLITIES
5.1 RIGHTS
In addition to the rights and benefts conferred by the
other terms of this Contract, Members shall have the fol-
lowing specifc rights:
A. Each adult Member shall have the right, on a yearly
basis, to vote for the election of members to the
HPP Board of Directors.
In addition, at least one-third (1/3) of the members
of HPPs Board of Directors must be adult Members
who are not compensated ofcers or employees, or
others responsible for the conduct of, or fnancially
interested in, HPPs afairs.
B. Each Member shall receive periodic HPP news-
letters providing information concerning voting
rights, current benefts and policies, maintaining
and improving health, and other items of general
interest.
C. Each Member shall have the right, upon request, to
information on the structure and operation of HPP.
D. An adult Member may change his/her selection of
Primary Care Physician upon notice to HPP. Changes
for an enrolled child can only be made by the par-
ent or guardian as identifed by MDCH, unless oth-
erwise permitted by order of court. Changes will be
efective on the frst day of the month following no-
tice.
E. Members and potential Members have the right to
oral interpretation services for any language and
written information for Prevalent Languages. Infor-
mation may also be available in alternate formats.
Members should contact HPPs Customer Service
Department to access these services or information.
F. When Members have questions or problems, they
can call the Customer Service Department at 1-800-
332-9161 (TDD: 1-800-992-5070). Customer Service
staf will document and date the source of all Mem-
ber contacts. Most inquiries can be resolved within
two (2) working days.
HPP will provide Members reasonable assistance
in completing forms and taking other procedural
steps.
If Members are not happy with any aspect of HPPs
operations or benefts, and cannot resolve their
concerns with the Customer Service Department,
Members or their Authorized Representative can
use the Member Satisfaction Plan.
1. Routine Grievance
The Member Satisfaction Plan has two inter-
nal steps for routine grievances: Grievance and
Grievance Appeal. HPP has thirty-fve (35) cal-
endar days to complete these two (2) steps, but
can extend the time by up to ten (10) business
days if HPP or a Member (or his or her Autho-
rized Representative), requests it. Here is how to
use each of the steps:
a. Step One: Grievance
Members (or their Authorized
Representative) can initiate this process
by contacting HPP by phone (1-800-332-
9161), mail (2050 S. Linden Road, P.O. Box
1700, Flint, Michigan, 48501-1700), fax
(1-810-733-1947), or arranging a personal
meeting. HPP will respond in writing to
Members
Grievances within ffteen (15) calendar
days of receiving it. At that time, Members
will be informed of HPPs investigation
into the Grievance, any action taken,
and information regarding the Member
Satisfaction Plan, including the Members
rights to further review if the Grievance was
not resolved in their favor.
If an Authorized Representative fles a
Grievance on behalf of a Member, the
Grievance is not considered to be received
by HPP until any necessary written
authorization form has been received by
HPP.
b. Step Two: Grievance Appeal
A Member dissatisfed with the outcome
of a Grievance may appeal it within fve (5)
calendar days following notifcation of the
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HealthPlus Partners Subscriber Contract
decision. HPP staf will schedule a meeting
of the Grievance Appeal Committee within
thirteen (13) calendar days of receipt of a
Members request to appeal a Grievance.
Members have the opportunity to appear
and speak before the Grievance Appeal
Committee with or without representation.
If a Member cannot appear in person, he or
she may also have the option of speaking by
telephone or other appropriate technology.
Members will receive notifcation of the
Grievance Appeal Committees decision
within two (2) calendar days of the
meeting. This will be HPPs fnal decision on
the Grievance. Members will be advised of
their right to further appeal to the State of
Michigan, DIFS.
c. External Review
If Members (or their Authorized Represen-
tative) have exhausted their rights under
the HPP Member Satisfaction Plan, or if they
have not received a response from HPP at
the end of ffteen (15) calendar days from
fling their appeal under Step Two: Griev-
ance Appeal, they can appeal to DIFS at no
cost to the Member by writing or calling:
Department of Insurance and Financial
Services, Healthcare Appeals Section,
Ofce of General Counsel/PRIRA, P.O. Box
30220, Lansing, Michigan 48909-7720 or
call 1-517-373-0220 or 1-877-999-6442 (toll
free), or fax at 1-517-241-4168.
By submitting a request for external
review, Members are authorizing HPP and
the Members health care Providers to
disclose their Personal Health Information,
including medical records, that are relevant
to the review process.
If the fnal decision of HPP was an Adverse
Determination, a Member must fle his or
her request for external review with DIFS
within sixty (60) calendar days following
receipt of HPPs fnal adverse decision.
If a Members request for external review
of an Adverse Determination is found to
be appropriate for external review, the
Director of DIFS will review the case and
may refer the case to an IRO, made up of
independent clinical reviewers, to review
the case. Both HPP and the Member
will have an opportunity to provide the
IRO with supporting documentation.
Within fourteen (14) calendar days, a
recommendation will be made to the
Director to uphold or reverse HPPs
determination. The Director has seven (7)
business days to make a decision.
If a Members request for external review
does not involve an Adverse Determination,
but is found to be appropriate for external
review, the Director will assign his or her
staf to review the case. Within fourteen
(14) calendar days, the Director will make a
decision.
G. Expedited Grievance
1. HPP Review
An Expedited Grievance process may be uti-
lized for Urgent Care Claims. Members may
only request an Expedited Grievance when HPP
has denied the request for benefts prior to the
Member having received a service.
HPP will determine whether an Expedited
Grievance is warranted based on the particu-
lar facts and circumstances of each request.
In making such a determination, HPP will ap-
ply the judgment of a prudent layperson who
possesses an average knowledge of health and
medicine; however, HPP will consult with an ac-
tively practicing Practitioner from the same or
similar specialty that typically treats the medi-
cal condition, performs the procedure, or pro-
vides the treatment in question. If an Expedited
Grievance is not warranted, the routine Griev-
ance process will be followed.
HPP will make a determination concerning the
Expedited Grievance and communicate that to
the Member and his/her Physician as expedi-
tiously as the medical condition requires, but
no later than seventy-two (72) hours after re-
ceipt. The Member and his/her Physician will
be provided with written confrmation of this
determination within two (2) calendar days fol-
lowing the oral notifcation.
Members (or their Authorized Representative)
may request up to a ten (10) calendar day ex-
tension of an Expedited Grievance. However, an
extension of an Expedited Grievance will move
the Grievance from the expedited process to
the routine process. HPP will notify the Member
(or his or her Authorized Representative) of this
change in timing and, if the Member (or his or
her Authorized Representative) still requests
the extension, the Expedited Grievance will be
moved to the routine process. If the Member
(or his or her Authorized Representative) with-
draws the request for an extension, the deter-
mination will be made within seventy-two (72)
hours after HPP receives the Members (or his
or her Authorized Representatives) original re-
quest for an Expedited Grievance.
2. External Review
A request for a further expedited review may
be forwarded to DIFS at no cost to the Member
within ten (10) calendar days following receipt
of an Adverse Determination on an Expedited
Grievance from HPP (or Outside Review Entity).
The Member may write or call them at the fol-
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HealthPlus Partners Subscriber Contract
lowing address and telephone number: De-
partment of Insurance and Financial Services,
Healthcare Appeals Section, Ofce of General
Counsel/PRIRA, P.O. Box 30220, Lansing, Michi-
gan 48909-7720 or call 1-517-373-0220 or
1-877-999-6442 (toll free) or fax at 1-517-241-
4168.
By submitting a request for external review,
Members are authorizing HPP and the Mem-
bers health care Providers to disclose their
Personal Health Information, including medical
records, that are relevant to the review process.
If a Physician believes that due to the Members
medical condition, resolution of the Expedited
Grievance within HPPs time frames for an Expe-
dited Grievance would seriously jeopardize the
Members life, health or ability to regain maxi-
mum function or subject a Member to severe
pain that cannot be managed adequately, and
the Member has fled a request for an Expedited
Grievance with HPP, the Member may request
an expedited external review from DIFS.
Upon receipt of a Members request, the Direc-
tor will immediately decide if it is appropriate
for external review and, if so, assign it to an IRO.
If the IRO decides that a Member does not have
to frst complete the HPP Expedited Grievance
process, it will review the Members case and
make a recommendation to the Director within
thirty-six (36) hours to uphold or reverse HPPs
determination. The Director has twenty-four
(24) hours to make a decision.
H. Initial Claim Decisions
1. Time Frame for Decisions
a. For Urgent Care Claims, HPP will notify the
Member of its initial decision on the Claim
as soon as possible, but no later than one
(1) calendar day after making the decision.
If the Member seeks review of an Urgent
Care Claim decision, the Member will be
instructed to fle an Expedited Grievance
using the Member Satisfaction Plan.
b. For Pre-Service Claims, HPP will notify the
Member of its initial Claim decision within
a reasonable time appropriate to medical
circumstances but not later than fourteen
(14) calendar days after receiving the
Claim. If a Member seeks review of a Pre-
Service Claim decision, the Member will
be instructed to fle a Grievance using the
Member Satisfaction Plan.
c. For Post-Service Claims, HPP will provide
notice of its initial decision within a
reasonable time, but not later than thirty
(30) calendar days after receiving the Claim.
(This time frame requirement concerns the
decision of the Claims only and not the time
frame for payment.)
d. Concurrent Care Decisions may be subject
to special time frames.
Concurrent Care Decisions are those
afecting an ongoing course of treatment
that will take place over a period of time
or a number of treatments. For Concurrent
Care Decisions regarding inpatient,
intensive outpatient behavioral health
and residential behavioral health, HPM will
make the decision within one (1) calendar
day. HPM will notify Members within two
(2) working days of making the decision.
For Concurrent Care Decisions regarding
ongoing ambulatory care, HPP will notify
Members within eleven (11) working days
of making the decision. HPPs decision to
reduce or terminate the course of treatment
is treated as an Adverse Determination
subject to review, and HPP must give notice
of the decision early enough to allow the
Member receiving the treatment to request
a review and receive a review decision
before the reduction or termination occurs.
A Members request to extend a course
of treatment may involve an Urgent Care
Claim, a Pre-Service Claim, or a Post-Service
Claim (depending on the type of treatment
and other circumstances). If the request
involves an Urgent Care Claim, HPP will
notify the recipient of its Concurrent Care
Decision within twenty-four (24) hours,
provided that the request is made at least
twenty-four (24) hours before the course of
treatment expires. If the request involves
a Pre-Service or Post-Service Claim, it is
subject to the time frame for other Claims
of the same type.
e. For termination, suspension or reduction
of a previously authorized Covered Service,
HPP will provide notice of its decision
generally within ten (10) days before the
action is taken. Exceptions to this ten (10)
day advance notice requirement include:
(1) Factual information confrming the
death of the Member;
(2) The Members whereabouts are
unknown and the mail directed to him/
her is returned with no forwarding
address; or
(3) A change in the level of medical care
has been prescribed by the Members
Physician.
2. Extensions
a. For Pre-Service Claims and Post-Service
Claims, if HPP determines that, for reasons
beyond the control of HPP, an extension
is necessary to reach an initial Claim
decision, a single ffteen (15) day extension
is permitted. To use the extension, HPP will
notify the Member in writing (by the date
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HealthPlus Partners Subscriber Contract
in which notice of the initial decision would
normally be due) of the circumstances
that require the extension and the date
by which HPP expects to reach a decision.
If the extension is necessary because
the Member fails to provide information
that HPP requires to reach a decision, the
notice will specifcally describe the missing
information and HPP will allow the Member
at least forty-fve (45) days to provide the
information. The time frames begin to run
from receipt of the Claim, even if the Claim
is incomplete. The time period for notice of
the initial decision is tolled, however, from
the time the notice of the extension is sent
to the Member until the Member responds
to the request for additional information.
HPP may not further extend the time for
making its decision unless the Member
agrees to a further extension.
b. Extensions are not permitted for decisions
on Urgent Care Claims.
3. Notice of Incomplete Claims or Improper Filing
a. HPP will notify a Member who has failed to
submit an Urgent Care or Pre- Service Claim
properly. The notice will describe the failure
and the proper procedures to be followed.
It will be provided as soon as possible but
not later than fve (5) calendar days after the
failure occurs (twenty-four (24) hours in the
case of an Urgent Care Claim).
b. For an Urgent Care Claim, HPP will also notify
the Member if the Claim is incomplete. This
notice will be provided as soon as possible
but not later than twenty-four (24) hours
after receiving the Claim. The notice will
identify the specifc information necessary
to complete the Claim. HPP will allow the
Member at least forty-eight (48) hours to
provide the information described in the
notice. HPP will also notify the Member of
its decision within forty-eight (48) hours
of the time that the Member provides the
information or the period for doing so
expires, whichever comes frst.
c. HPP is not required to notify Members
who have submitted Post-Service Claims
improperly.
4. Manner and Content of Notifcation of Adverse
Determination. Members will be provided with
written or electronic notifcation of any initial
Adverse Determination. The notifcation will set
forth, in a manner calculated to be understood
by the Member, all of the following:
a. the action HPP has taken or intends to take.
b. the specifc reason or reasons for the
Adverse Determination.
c. reference to the specifc plan provisions on
which the determination is based.
d. a description of any additional material
or information necessary for the Member
to perfect the Claim and any explanation
of why such material or information is
necessary.
e. a description of HPPs Member Satisfaction
Plan for fling a Grievance and the time
limits applicable to such procedures.
f. a copy or a statement that a rule, guideline
or protocol was relied upon and is
available upon request and free of charge
(if an internal rule, guideline or protocol
was relied upon in reaching an Adverse
Determination).
g. an explanation of the scientifc or clinical
judgment behind the determination, or a
statement that the explanation is available
upon request (if the adverse decision
is based on a determination of medical
necessity, experimental treatment or similar
exclusion or limitation).
h. a description of the expedited review
process (contained in the Member
Satisfaction Plan) applicable to the Claim (for
Urgent Care Claims).
i. the Members right to fle a State fair hearing
request.
j. the Members right to have benefts continue
pending resolution of the Grievance, how to
request that benefts be continued, and the
circumstances under which the Member
may be required to pay for costs of these
services.
I. Obtaining Appropriate Referral and/or Prior Autho-
rization
1. If the Members Primary Care Physician deter-
mines that the Member requires additional
care, the Primary Care Physician will initiate the
appropriate referral process. The Member will
receive either written notifcation from HPP, or a
referral from the Primary Care Physician, which
will specify the number of visits and the length
of time covered by the referral. If the referral
expires and the Member needs additional vis-
its, the Member should contact his/her Primary
Care Physician.
2. If the Provider to whom the Primary Care Phy-
sician is referring the Member does not partici-
pate with HPP (i.e., a Non-Afliated Provider),
the Primary Care Physician will initiate the out-
of-plan referral process. Only services approved
by HPP prior to visiting a Non-Afliated Provider
will be covered. The Member will receive a deci-
sion in writing, usually within fve (5) to seven
(7) business days from the time the referral is
received by HPP. If the referral to the Non-Afli-
ated Provider is not approved, HPP will explain
the reason for the denial.
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HealthPlus Partners Subscriber Contract
3. Primary Care Physicians know that certain pro-
cedures or items require prior authorization by
HPP. If a Member has further questions regard-
ing this issue, the Member should talk with his/
her Primary Care Physician or call HPP Customer
Service.
J. Other Procedural Information Regarding Review of
Claim Decisions and the Member Satisfaction Plan.
1. The Grievance process does not apply to a Pro-
viders complaint concerning Claims payment,
handling or reimbursement for health care ser-
vices.
2. The Grievance must be fled within ninety (90)
calendar days following the date of receipt of
the notice of Adverse Determination.
3. The Member will be provided with the written
or electronic notifcation of HPPs fnal determi-
nation. Such notifcation shall be in plain Eng-
lish (or translated as necessary). In the case of
a fnal Adverse Determination, the notifcation
must set forth, in a manner calculated to be un-
derstood by the Member, all of the following:
a. the specifc reason or reasons for the
Adverse Determination.
b. reference to the specifc plan provisions on
which the determination is based.
c. a statement that the Member is entitled to
receive, upon request and free of charge,
reasonable access to, and copies of all
documents, records, and other information
relevant to the Members Claim for benefts.
d. a copy or a statement that a rule, guideline
or protocol was relied upon and is
available upon request and free of charge
(if an internal rule, guideline or protocol
was relied upon in reaching an Adverse
Determination).
e. an explanation of the scientifc or clinical
judgment behind the determination, or a
statement that the explanation is available
upon request (if the Adverse Determination
is based on a determination of medical
necessity, experimental treatment or similar
exclusion or limitation).
4. Members may submit written comments, docu-
ments, records, and other information relating
to the Claim or Grievance.
5. Review of the Claim or Grievance will take into
account all comments, documents, records, and
other information submitted by the Member re-
lating to the Claim or Grievance, without regard
to whether such information was submitted or
considered in the initial Adverse Determination.
6. The original Physician or Practitioner who made
the denial will be consulted frst to see whether
he/she upholds the denial. If the denial is up-
held, a non-involved Physician or Practitioner
will be consulted.
7. Review of the Grievance will not aford defer-
ence to the initial Adverse Determination and
will be conducted by an appropriate named
employee of HPP who is neither the individual
who made the Adverse Determination that is
the subject of the appeal nor the subordinate of
such individual.
8. In deciding an appeal of any Adverse Deter-
mination that is based in whole or in part on
a medical judgment, including determinations
with regard to whether a particular treatment,
drug, or other item is experimental, investiga-
tional, or not medically necessary or appropri-
ate, the appropriate named HPP employee will
consult with an actively practicing Practitioner
from the same or similar specialty that typically
treats the medical condition, performs the pro-
cedure, or provides the treatment in question.
9. Identifcation of the title and qualifcations of in-
dividuals whose advice was obtained on behalf
of HPP in connection with a Members Adverse
Determination will be provided to the Member
upon request, without regard to whether the
advice was relied upon in making the beneft
determination. The individual(s) engaged for
purposes of a consultation will be an individual
who was not consulted in connection with the
Adverse Determination that is the subject of the
appeal, nor the subordinate of any such individ-
ual.
10. At any point in time the Member (or his or her
Authorized Representative) may request HPP to
delay the processing of their Claim or Grievance
for up to ten (10) business days. The Member
may request the delay if more time is needed
to obtain medical records or other information
pertinent to resolving the Claim or Grievance,
or if personal issues make the timing not con-
venient for the Member. Likewise, at any point
in time, Member Satisfaction staf may delay
processing a Members Grievance for up to ten
(10) business days if HPP can show that there is
a need for additional information and the delay
is in the Members interest. If HPP extends the
time period, it will give the Member (or his or
her Authorized Representative) written notice
of the reason for the delay.
11. Claims determinations and the Member Satis-
faction Plan will not be administered in any way
that duly inhibits or hampers the initiation or
processing of a Claim or fling a Grievance (e.g.,
a requirement that a fee be paid as a condition
to making a Grievance or appealing an Adverse
Determination). Claims determinations and the
Member Satisfaction Plan will be applied con-
sistently with respect to similarly situated Mem-
bers.
12. If the Member requests, Health Care Benefts
will continue if the Member fles an appeal or
requests a fair hearing within the required time-
Page37
HealthPlus Partners Subscriber Contract
frames. However, the Member may be required
to pay the cost of services furnished while the
appeal is pending if the fnal decision is not in
the Members favor.
13. If the fnal resolution of the Grievance or State
fair hearing decision is adverse to the Member,
HPP may recover the cost of the related services
furnished to the Member while the appeal is
pending, to the extent that they were furnished
solely because of state or federal requirements.
14. HPP will continue benefts pending resolution
of a Grievance fled with HPP or a State fair hear-
ing decision if the following fve (5) conditions are
met:
a. the Member, or his/her Authorized
Representative, fled the Grievance or State
fair hearing request timely (within ten (10)
calendar days of HPP mailing the notice of
the Adverse Determination);
b. the Grievance or State fair hearing request
involves termination, suspension or
reduction of a previously authorized course
of treatment;
c. the services were ordered by an Plan
Provider;
d. the original period covered by the original
Appropriate Referral has not expired; and
e. the Member requests the extension of
benefts.
15. The benefts will continue under paragraph 14
above until one of the following occurs:
a. the Member withdraws the appeal;
b. ten (10) calendar days pass after HPP
mails the notice, providing resolution of
the appeal against the Member, unless
the Member, within the ten (10) calendar
day timeframe, has requested a State fair
hearing with continuation of benefts until
a State fair hearing decision is reached;
c. a State fair hearing ofce issues a hearing
decision adverse to the Member; or
d. the time period or service limits of a
previously authorized service have been
met.
K. State Medicaid Fair Hearing Process. Members or
their Authorized Representative, may fle a com-
plaint directly with the State. Members do not have
to contact HPP Customer Service staf or fle a Griev-
ance under the Member Satisfaction Plan before
contacting the State. Listed below are the steps for
the State Medicaid fair hearing process.
1. Call 1-800-642-3195 to have a hearing request
(complaint) form sent to you. You may also call
to ask questions about the hearing process.
2. Fill out the request (complaint form) and return
it to the address listed on the form.
3. You will be sent a letter telling you when and
where your hearing will be held, ten (10) days
prior to the hearing.
4. The results will be mailed to you within ten (10)
days after the hearing is held. If your complaint
is taken care of before your hearing date, you
must call to ask for a hearing request withdraw-
al form. You can call 1-800-642-3195 to request
this form.
L. Statement of Rights Under the Newborns and
Mothers Health Protection Act.
Under federal law, group health plans and health
insurance issuers (including health maintenance
organizations) ofering health coverage generally
may not restrict benefts for any hospital length of
stay in connection with childbirth for the mother
or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a
delivery by cesarean section. However, the plan or
issuer may pay for a shorter stay if the attending
Provider (e.g., your Physician), after consultation
with the mother, discharges the mother or newborn
earlier.
Also, under federal law, plans and issuers may not
set the level of benefts or out-of-pocket costs so
that any later portion of the 48-hour (or 96-hour)
stay is treated in a manner less favorable to the
mother or newborn than any earlier portion of the
stay.
In addition, under federal law, a plan or issuer may
not require that a Physician or other health care
Provider may obtain authorization for prescrib-
ing a length of stay of up to 48 hours (or 96 hours).
However, to use certain Providers or facilities, or to
reduce your out-of- pocket costs, you may be re-
quired to obtain pre-certifcation.
M. Members have the right to request and receive
a copy of their medical record and request it be
amended or corrected.
N. Members have the right to be free from any form of
restraint or seclusions used as a means of coercion,
discipline, convenience, or retaliation.
O. Members have the right to discuss treatment op-
tions and express preferences about treatment op-
tions without regard to cost or beneft coverage.
P. Members have the right to get medical care regard-
less of race, color, religion, sex, sexual orientation,
age, disability, national origin, veterans status and
stay, health status or need for health services con-
sistent with the State contract, State and Federal
regulations.
Q. Members shall have the right, upon request, to in-
formation on the structure and operation of HPP.
5.2 RESPONSIBILITIES
In addition to the Member responsibilities which exist
under the other terms of this Contract, Members shall
have the following duties:
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HealthPlus Partners Subscriber Contract
A. A Member must select a Primary Care Physician
upon enrolling with HPP or immediately upon dis-
charge of his/her previous Primary Care Physician.
If a Member does not select a Primary Care Physi-
cian within thirty (30) calendar days of enrollment,
the plan will assign a provider and the Member will
be notifed. A Member always retains the right to
change the Primary Care Physician at any time.
B. A Member shall notify HPP within twenty-four (24)
hours of any emergency admission or admission to
a Non-Afliated Hospital.
C. A Member shall notify HPP and the Department of
Human Services of any change in name, address,
marital status, dependency status, or any other
criteria of eligibility within thirty (30) days of the
change.
D. A Member shall immediately notify HPP, in writing, of
any loss or theft of his/her Identifcation Card.
E. A Member shall not allow any other person to use
his/her Identifcation Card or otherwise allow oth-
ers to erroneously represent his/her identity as an
HPP Member.
F. A Member may, for personal or religious reasons,
refuse to accept procedures or treatment recom-
mended as necessary by his/her treating Physician.
If a Member refuses appropriate care recommended
by his/her treating Physician and no alternative care
exists in the opinion of the Members treating Physi-
cian, Health Care Benefts shall not be extended by
this Contract for the condition under treatment.
G. A Member shall be responsible for all services ren-
dered prior to his/her Efective Date of Coverage
and following the Efective Date of Termination,
unless a Member is hospitalized at the time of ter-
mination. HPP shall be entitled to recover from Pro-
viders all claims payments made by HPP for services
rendered to the Eligible Individual and/or Eligible
Dependent after the Efective Date of Termination.
H. A Member shall be responsible for payment of all
services which are not Covered Services.
I. A Member shall execute any and all releases neces-
sary in order for HPP or its designee to gain access
to the Members medical records, including mental
health and substance abuse records.
J. A Member shall enroll in Part B of Medicare upon
their frst date of eligibility under Title XVIII of the
Social Security Act, and shall notify HPP of the date
their Medicare coverage begins.
SECTION VI
RECORDS
6.1 MEMBERSHIP RECORDS
HPP shall keep records concerning eligibility and claims
paid on behalf of Members for a reasonable period of
time. Members and/or Group shall forward information
periodically as required by HPP in connection with the
administration of this Contract.
6.2 INSPECTION OF RECORDS BY MEMBER
Any Member may review his/her own records at the of-
fces of HPP during regular business hours. An appoint-
ment for this purpose shall be required.
6.3 ACCURACY OF INFORMATION
HPP shall not be liable for the inaccuracy of any retained
information furnished by the Member or Group. Incor-
rect information furnished to HPP may be corrected by
a Member if HPP has not acted to its prejudice by relying
on it.
6.4 CONFIDENTIALITY OF PERSONAL HEALTH INFORMA-
TION
Members should refer to HPPs Privacy Notice (mailed to
Members upon enrollment and annually thereafter) for
a description of how personal and medical information
about Members may be used and disclosed and how
Members can get access to this information.
SECTION VII
TERMINATION OF COVERAGE
7.1 TERMINATION
A. Coverage under this Contract ends immediately
when a Member is no longer eligible for services
under the Medicaid Program in accordance with
the terms of this Contract or the contract between
HPP and the Michigan Department of Community
Health or as otherwise determined by the Michigan
Department of Community Health or its designee.
If a Member is receiving inpatient Hospital services
on the Efective Date of Termination, Hospital ben-
efts shall continue for the condition under treat-
ment until the date of discharge from the Hospital,
or expiration of the beneft, whichever comes frst.
7.2 DISENROLLMENT
A. If a Member wishes to disenroll, he/she must follow
the procedures set forth by the Michigan Depart-
ment of Community Health or its designee. Disen-
rollment information is available upon request from
the HPP Customer Service Department and the
Michigan Department of Community Health or its
designee.
B. All rights to Health Care Benefts cease as of the ef-
fective date of disenrollment without prejudice to
any current claims. The disenrollment date will be
determined by the Michigan Department of Com-
munity Health or its designee. The Member will be
notifed of said date in writing.
If a Member is receiving inpatient Hospital services
on the Efective Date of Termination, Hospital ben-
efts shall continue for the condition under treat-
ment until the date of discharge from the Hospital,
or expiration of the beneft, whichever comes frst.
C. If the contract between HPP and the Michigan De-
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HealthPlus Partners Subscriber Contract
partment of Community Health pursuant to which
this Contract is issued is terminated, Members will
be assisted in returning to Medicaid or another
comparable program, if available.
7.3 DISENROLLMENT FROM HPP
A. HPP may disenroll a Member on the date specifed
by HPP, after receiving consent from the Michigan
Department of Community Health, for the following
reasons:
1. if the Member fails to meet any eligibility re-
quirement for participation in HPP or the Med-
icaid Program according to the Michigan De-
partment of Community Health or its designee.
2. for willingly and knowingly providing false or
misleading information or withholding material
information on the Application.
3. for permitting the use or misuse of the HPP
Identifcation Card by any other person, or if the
Member uses another persons Identifcation
Card.
4. if the Members behavior is disruptive, unruly,
abusive, or uncooperative to HPP personnel,
Afliated Providers, other providers, or other
Members.
5. if after reasonable efort, the Member and the
Primary Care Physician are unable to establish
and/or maintain a satisfactory provider/patient
relationship.
6. if the Member has a medical condition of such
magnitude (unknown by HPP at the time of
enrollment) that interruption of an established
regimen could be detrimental to the persons
health.
7. if a Member obtains or attempts to obtain
Health Care Benefts fraudulently.
8. if the Member no longer Resides in the Service
Area.
9. if the Member breaches any term or condition
of the Contract.
10. if the Member enters into active military duty,
except for temporary duty of thirty (30) days or
less.
7.4 EFFECTIVE DATE OF TERMINATION
The Efective Date of Termination is the earliest date this
Contract may be considered terminated under this Sec-
tion.
SECTION VIII
COVERED SERVICES
The services and benefts described in this Section VIII are ofered
in accordance with HPPs policies and procedures for beneft
administration. Except for Emergency Health Services and except
as otherwise provided below, coverage under this Contract is only
available for those services and benefts authorized in advance by
the Members Primary Care Physician and/or HPP in accordance
with all HPP policies and procedures. Only services that are
Medically Necessary according to generally accepted standards
of practice as determined by an HPP Medical Director are Covered
Services under this Contract.
Subject to the Limitations and Exclusions of Section IX, Covered
Services include:
8.1 PHYSICIAN SERVICES (other than Mental Health Servic-
es) provided by, or under the direction of, the Members
Primary Care Physician, or provided by a Specialist Phy-
sician to whom the Member is Appropriately Referred,
including:
A Ofce Visits for treatment of illness or injury.
B. Periodic routine physical examinations or health as-
sessments by the Members Primary Care Physician.
C. Pediatric care, including well-child care, and diag-
nosis and treatment of illness and injury. D.
Pediatric and adult immunizations in accordance
with accepted medical practice.
E. Maternity care, delivery, postpartum, miscarriage,
and other related obstetrical services, including
midwives. Self-referral to an in-plan obstetrician/
gynecologist for an annual well- woman exam and
routine obstetrical services.
F. Professional services by Specialist Physicians.
G. Hospital Visits as part of continued supervision of
covered care.
H. Allergy services, including allergy survey, allergy
testing, allergy serum, and injections of allergy se-
rum.
I. Services by a Podiatrist.
COPAYMENT FOR PHYSICIAN OFFICE VISITS:
There will not be a Copayment for Physician Ofce Visits.
8.2 HOSPITAL SERVICES (excluding Mental Health Services
and Substance Abuse Services) when provided by a
Hospital, when authorized by HPP and when under the
direction of the Members Primary Care Physician or a
Specialist Physician to whom the Member is Appropri-
ately Referred, including:
A. Inpatient services, including:
1. Semi-private room and board, including gen-
eral duty nursing care.
2. Private room and board accommodations for
medical reasons when authorized by a Plan
Physician.
3. Therapeutic and support care, services, sup-
plies, and appliances.
4. Care in specialized units.
5. Use of operating, delivery, recovery, and treat-
ment rooms and equipment.
6. Laboratory tests, X-rays, EKGs, EEGs, and other
diagnostic tests performed in conjunction with,
or following, admission to the Hospital.
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HealthPlus Partners Subscriber Contract
7. Anesthetics, oxygen, drugs, and other biologi-
cals.
8. Dressings, casts, and special equipment when
supplied by the Hospital for use in the Hospital.
9. Special diets.
10. Radiation, inhalation, and physical, occupation-
al, and speech therapies.
11. Medical rehabilitation, including Short-Term
rehabilitation services and Short-Term physical,
occupational, and speech therapies.
12. Administration of whole blood and blood de-
rivatives.
13. Phase I cardiac rehabilitation services.
14. Dialysis for End Stage Renal Disease.
B. Outpatient services, including:
1. Use of operating, delivery, recovery, and treat-
ment rooms and equipment.
2. Laboratory tests, X-rays, EKGs, EEGs, and other
diagnostic tests.
3. Anesthetics, oxygen, Prescription Drugs, and
other biologicals.
4. Dressings, casts, and special equipment.
5. Therapeutic and support care, services, sup-
plies, and appliances.
6. Radiation, inhalation, and physical, occupation-
al, and speech therapies.
7. Medical rehabilitation, including Short-Term
rehabilitation services and Short-Term physical,
occupational, and speech therapies.
8. Administration of whole blood and blood de-
rivatives.
9. Phase II cardiac rehabilitation services, lim-
ited to twenty-four (24) sessions in twelve (12)
weeks.
10. Dialysis for End Stage Renal Disease.
COPAYMENT FOR INPATIENT HOSPITAL SERVICES:
There will not be a Copayment for inpatient hospi-
tal services.

COPAYMENT FOR OUTPATIENT HOSPITAL SERVICES:
There will not be a Copayment for outpatient hos-
pital services
8.3 EMERGENCY HEALTH SERVICES, including:
A. Hospital Emergency Room (in or out of the Service
Area).
B. Freestanding Emergency Center (in or out of the
Service Area). C. Physician services when
billed separately from facility charges.
HPP reserves the right not to pay for treatment at
emergency facilities if the presenting symptoms
were not severe enough to suggest the need for im-
mediate medical attention.
COPAYMENT FOR HOSPITAL EMERGENCY ROOM
VISITS: There will not be copayments for non-emer-
gency health service visits.
8.4 PREVENTIVE HEALTH SERVICES provided to a Member by,
or under the direction of, the Members Primary Care Phy-
sician or provided by a Specialist Physician to whom the
Member is Appropriately Referred, including:
A. Periodic routine physical examinations or health
assessments by the Members Primary Care Physi-
cian, including blood lead testing (must be tested
by twelve (12) months of age and twenty-four (24)
months of age), hearing and vision screening as a
preventive and early detection mechanism and ear-
ly and periodic screening, diagnosis and treatment
(EPSDT) services for Members under twenty-one
(21) years of age.
B. Pediatric and adult immunizations in accordance
with accepted medical practice. C. Pr e na t a l
care and counseling.
D. Health education and health counseling services. E.
Tobacco cessation services.
8.5 MENTAL HEALTH SERVICES when authorized in advance
by HPP or its designee, and when under the direction
or care of an HPP Preferred Mental Health Provider or
a Mental Health Provider to whom HPP or its designee
has given prior authorization for services, including:
A. Outpatient Mental Health Services.
B. Coordination of care with local Community Mental
Health Boards.
8.6 DIAGNOSTIC LABORATORY SERVICES (other than pro-
vided in a Hospital) when provided by Afliated labo-
ratories, when ordered and/or authorized in advance by
the Members Primary Care Physician or a Specialist Phy-
sician to whom the Member is Appropriately Referred
and/or HPP, and when said services are in support of
other Health Care Benefts set forth in this Contract.
8.7 DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL SER-
VICES (other than provided in a Hospital) when provided
by Afliated Providers, when ordered and/or authorized
in advance by the Members Primary Care Physician or
a Specialist Physician to whom the Member is Appro-
priately Referred and/or HPP or its designee, and when
said services are in support of other Health Care Benefts
set forth in this Contract, including:
A. Electrocardiograms.
B. Electroencephalograms.
C. Diagnostic X-rays.
D. Radiation therapy.
E. Breast cancer screening mammograms in accordance
with Section 3406d of the Insurance Code.
F. Other medically acceptable diagnostic or therapeutic
procedures.
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HealthPlus Partners Subscriber Contract
8.8 SHORT-TERM MEDICAL REHABILITATION SERVICES in ac-
cordance with Medicaid guidelines when provided on
an outpatient basis by Afliated Providers, and when
authorized in advance by the Members Primary Care
Physician and/or HPP, including Short-Term rehabilita-
tion and Short- Term physical, occupational, and speech
therapies.
8.9 HOME HEALTH SERVICES in accordance with Medicaid
guidelines when provided in the Members home by
Afliated Providers, when the Member is confned to
home, and when authorized in advance by the Mem-
bers Primary Care Physician and/or HPP for a Skilled
level of Care, including:
A. Intermittent Skilled Nursing Care
B. Short-Term physical therapy
C. Part-time health aid services
8.10 AMBULANCE SERVICES
Authorized emergency vehicle and personnel which
provide Emergency Health Services and transportation
to a Provider where Emergency Health Services and
treatment can be rendered. Any other use of ambulance
services requires authorization in advance by the Mem-
bers Primary Care Physician and/or HPP.
8.11 DURABLE MEDICAL EQUIPMENT, ORTHOTIC APPLIANC-
ES, AND PROSTHETIC DEVICES when obtained from Af-
fliated Providers or suppliers, when determined by HPP
to be an eligible item and when ordered and/or autho-
rized in advance by the Members Primary Care Physi-
cian or a Specialist Physician to whom the Member is
Appropriately Referred and/or HPP.
8.12 HEARING AIDS
Benefts for a Hearing Aid(s) and hearing tests for ftting
and post performance evaluation of a Hearing Aid(s)
when authorized, in advance, by the Members Primary
Care Physician and obtained from an Afliated Provider.
COPAYMENT FOR HEARING AID SERVICES:
There will not be a Copayment for hearing aid services
8.13 DRUGS AND MEDICAL SUPPLIES
Benefts for Prescription Drugs and certain over-the-
counter drugs and medical supplies listed in the HPP
Medicaid formulary, except for carved-out behavioral
health medications (which are covered by MDCH),
when prescribed by a Plan Physician, Dentist, or a Non-
Plan Provider to whom a Member was Appropriately
Referred and when furnished by an Afliated Pharmacy
Provider.
COPAYMENT FOR DRUGS AND MEDICAL SUPPLIES:
There will not be a Copayment for prescriptions
Coverage under this Section 8.13 will include Federal
Food and Drug Administration-approved drugs used
for of-label purposes and the reasonable cost of sup-
plies medically necessary to administer the drug in ac-
cordance with Section 3406q of the Insurance Code.
HPP will cover Federal Food and Drug Administration-
approved drugs used in antineoplastic therapy in accor-
dance with Section 3406e of the Insurance Code.
8.14 FAMILY PLANNING SERVICES when obtained from Afli-
ated Providers, including:
A. Medically indicated genetic testing and counsel-
ing in accordance with generally accepted medical
practice.
B. Except as provided in Section 9.2 S, services for di-
agnosis of infertility when Medically Necessary in
accordance with generally accepted medical prac-
tice and/when authorized in advance by the Mem-
bers Primary Care Physician and HPP.
C. Contraceptive drugs, devices, supplies and other ap-
propriate family planning services for the purpose
of voluntarily preventing or delaying pregnancy or
for the detection or treatment of sexually transmit-
ted diseases. These services may be obtained from
any provider of choice without authorization from
the Members Primary Care Physician, including but
not limited to
Planned Parenthood, the local health department,
or an adolescent health center. D. Adult sterilization
procedures for Members over twenty-one (21) years
of age.
E. Termination of pregnancy is covered only when it is
determined medically necessary to save the life of
the mother or as otherwise required in accordance
with the Medicaid Program.
8.15 ORAL SURGERY AND RELATED SERVICES only when pro-
vided by Afliated Providers and authorized in advance
by HPP and the Members Primary Care Physician for the
following conditions:
A. Prompt repair and treatment of jaw fractures and
dislocation of the jaw immediately following an ac-
cident or traumatic injury.
B. Prompt repair of injury to the jaw, tongue, cheeks,
lips and roof/foor of the mouth immediately fol-
lowing an accident or traumatic injury (repair/resto-
ration of the teeth is not a Covered Service).
C. Orthognathic surgery prior to age twenty-one (21)
for congenital defects directly afecting the growth,
development, and function of the jaw.
D. Treatment of tumors, cysts, and lesions on or in the
mouth except when in connection with an extrac-
tion.
E. Hospitalization charges for multiple extractions
which must be performed in a Hospital due to a
concurrent hazardous medical condition.
8.16 ORGAN AND TISSUE TRANSPLANTS only when provided
by a Provider approved in advance by HPP to perform
such services, and only when authorized in advance by
HPP and the Members Primary Care Physician. Benefts
are limited to human organ or tissue transplant proce-
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HealthPlus Partners Subscriber Contract
dures that are Medically Necessary and not considered
to be Experimental. Medically Necessary hospital, sur-
gical, laboratory, and radiology expenses incurred by
a non-Member donor for an authorized transplant to a
Member will also be covered after it is determined that
the non-Members insurance is not sufcient to cover
the total cost of such expenses.
8.17 ROUTINE VISION SERVICES when authorized in advance
by HPP and obtained from Afliated Providers, Suppliers,
or Specialist Physicians, including:
A. Complete eye examination and refraction.
B. Corrective lenses (single vision, multi-focal, or cata-
ract lenses).
C. Eyeglass frames (or contact lenses, but only if re-
quired to be provided by the Medicaid Program).
D. Repair or replacement of frames/lenses due to body
growth, loss, or breakage when prior authorized.
COPAYMENT FOR VISION SERVICES:
There will not be a Copayment for vision services
8.18 HOSPICE SERVICES provided by an Afliated Hospice,
when ordered by the Members Primary Care Physician
and authorized, in advance, by HPP, including:
A. Room and board charges
B. Medical supplies, drugs, and medicines
C. Medical-social services
8.19 SHORT-TERM RESTORATIVE OR REHABILITATIVE NURS-
ING CARE services up to 45 days (within a rolling 12
month period from initial admission) of intermittent or
short-term restorative or rehabilitative services in accor-
dance with Medicaid guidelines provided by Afliated
Providers in or out of a facility (e.g. a Skilled Nursing
Facility) when authorized in advance by the Members
Primary Care Physician, Specialist Physician to whom
the Member is Appropriately Referred, and/or HPP. The
45-day maximum does not apply to restorative health
services provided in places of service other than a nurs-
ing facility.
8.20 CHIROPRACTOR OFFICE SERVICES when provided by
Afliated Chiropractors for the frst eighteen (18) visits.
Authorization required for any visits after the frst eigh-
teen (18).
COPAYMENT FOR CHIROPRACTOR SERVICES:
There will not be a Copayment for chiropractor services.
8.21 MISCELLANEOUS
A. HPP will cover Medically Necessary Reconstructive
surgery, including breast Reconstructive surgery
following a mastectomy, when authorized in ad-
vance by the Members Primary Care Physician, a
Specialist Physician to whom the Member is Appro-
priately Referred, and/or HPP.
B. HPP will cover Covered Services rendered at a child
and adolescent health center.
C. HPP will cover certain Covered Services rendered at
public health departments, rural health centers or
federally qualifed health centers as defned by state
Medicaid guidelines.
D. HPP will cover the following equipment, supplies
and educational training related to the treatment
of diabetes if determined to be Medically Necessary
and prescribed by the Members Primary Care Phy-
sician or a Specialist Physician to whom the Mem-
ber is Appropriately Referred:
1. blood glucose monitors and blood glucose
monitors for the legally blind.
2. test strips for glucose monitors, visual reading
and urine testing strips, lancets, and spring-
powered lancet devices.
3. insulin syringes.
4. insulin pumps and medical supplies required
for the use of an insulin pump.
5. diabetes self-management training to ensure
that Members with diabetes are trained as to
the proper self-management and treatment of
their condition.
With regard to coverage for diabetes self-man-
agement training, the following conditions ap-
ply:
a. it is limited to completion of a certifed
diabetes education program should either
of the following occur:
(1) if considered Medically Necessary
upon the diagnosis of diabetes by the
Members Primary Care Physician or
a Specialist Physician to whom the
Member is Appropriately Referred who
is managing the Members diabetic
condition and if the services are needed
under a comprehensive plan of care to
provide necessary skills and knowledge
or ensure therapy compliance.
(2) if the Members Primary Care Physician
or a Specialist Physician to whom the
Member is Appropriately Referred
diagnoses a signifcant change with
long-term implications in the Members
symptoms or conditions that requires
changes in the Members self-
management or a signifcant change in
medical protocol or treatment modality.
b. it shall be provided by a diabetes outpatient
training program certifed to receive
Medicaid or Medicare reimbursement or
certifed by the Department of Community
Health. This training shall be conducted in
group settings whenever practicable.
E. HPP will cover non-Emergency transportation to
and from any medical Covered Service when autho-
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HealthPlus Partners Subscriber Contract
rized in advance by HPP (see Member Handbook or
Provider Directory for transportation policy).
F. HPP will cover Medically Necessary weight reduc-
tion services for severely obese Members with high-
risk co-morbidities.
G. HPP will cover Medically Necessary out-of-state ser-
vices if authorized by HPP.
H. During pregnancy, your body goes through various
changes you may be unaware of.
Childbirth education classes will help you under-
stand these changes and help prepare you for deliv-
ery and taking care of your baby after the delivery.
HPP covers these classes provided by qualifed edu-
cators at most hospitals or through certifed Mater-
nal Infant Health Programs. Please see your doctor
for a referral.
SECTION IX
BENEFIT LIMITATIONS AND EXCLUSIONS
9.1 LIMITATIONS
The Covered Services set forth in Section VIII of this Con-
tract shall be limited in accordance with the provisions
of the Medicaid Program and in the following ways:
A. Outpatient Mental Health Services. The maximum
number of Outpatient Visits provided for mental
health evaluation and therapeutic services shall be
twenty (20) Visits per Member per calendar year.
B. Major Disasters. In the event of any major disaster,
epidemic, or other circumstances beyond its con-
trol, HPP shall render or attempt to arrange Covered
Services insofar as practical, according to its best
judgment, within the limitations of facilities and
personnel then available. However, no liability or
obligations are incurred for delay or failure to pro-
vide any such benefts due to lack of available fa-
cilities or personnel, if such lack is the result of such
disaster, epidemic or other circumstances beyond
HPPs control. Such circumstances include complete or
partial disruption of facilities, war, riot, civil insurrection,
disability of a signifcant part of a Afliated Provider or
plan personnel or similar causes.
C. Emergency Health Services. Members hospitalized
at Non-Afliated Hospitals may be transferred to an
Afliated Hospital upon request by the Members
Primary Care Physician as soon as it is medically
appropriate in the opinion of the attending physi-
cian. Should a Member, or his or her designee, re-
fuse a transfer to an Afliated Hospital, continued
care provided to that Member at a Non-Afliated
Hospital shall not constitute Covered Services and
shall no longer be the fnancial responsibility of HPP.
Coverage for Emergency Health Services provided
by a Non-Afliated Provider shall be limited to a
Reasonable Charge for said services. Any necessary
follow-up care after emergency treatment must be
provided, arranged, or authorized by the Members
Primary Care Physician.
D. Durable Medical Equipment, Orthotic Appliances
and Prosthetic Devices. Coverage shall be pro-
vided only for non-deluxe items, appropriate for
use at home, as determined by HPP to be eligible
for reimbursement. HPP shall determine whether
the equipment, appliance, or device shall be pur-
chased or rented. Covered Services include repair
to a serviceable condition, or replacement when
the equipment, appliance or device is irreparable
or the condition or size of the patient requires re-
placement, whichever is determined by HPP or its
designee to be appropriate. Orthotic Appliances are
covered only when they are used to support, align,
prevent, correct or improve a defect of body form or
function. Prosthetic Devices are covered only when
they replace a limb or other part of the body after
accidental or surgical removal and/or when the
Members body growth necessitates a replacement.
Comfort and convenience equipment, exercise and
hygiene equipment, dental appliances, experimen-
tal or research equipment, and self-help devices not
medical in nature are not a Covered Service. Any
equipment, appliance, or device ordered before the
Efective Date of Coverage will not be covered, even
if delivered after the Efective Date of Coverage.
Coverage of equipment, appliances, or devices for
Members under age twenty-one (21) may be lim-
ited or excluded in accordance with the provisions
of the Medicaid Program.
E. Prescription Drugs. Benefts for Prescription Drugs
in the HPP Medicaid formulary will be limited to the
reasonable cost of generically available products,
unless no generically equivalent product exists or
a Member specifc review for medical necessity by
HPP determines the need for brand name medica-
tion. HPP reserves the right to determine generic
equivalency of products available to HPP Members.
HPP reserves the right to review Prescription Drug
products and procedures for medical necessity, ef-
cacy of use, and quality to determine if they should
be available to HPP Members. Prior authorization,
quantity or dose limits may apply for certain medi-
cations.
F. Inappropriate and Unnecessary Services. Benefts
shall be limited to providing coverage for necessary
treatment as determined by reviewing the intensity
of service, severity of illness, appropriateness of ser-
vices rendered, and appropriateness of placement
in special units and selected clinical support facili-
ties. Services may be reviewed prospective, concur-
rent, or retrospective to the time of service. Such
review shall impact only the level of Coverage pro-
vided by HPM and shall not serve, or be construed
as, any limitation or infringement on any Members
right to select and pay for any level of care desired
in any location.
G. Chiropractic Services. Benefts are limited to one set
of x-rays of the spine per calendar year. A set of x-
rays is defned as a maximum of two (2) x-rays.
H. Vision Services. Benefts for Vision Services shall
be limited to one (1) complete eye examination
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HealthPlus Partners Subscriber Contract
and refraction per Member every two (2) calendar
years, unless deemed Medically Necessary more
frequently, and one (1) complete pair of eyeglasses
(frames and/or lenses) per Member every two (2)
calendar years when new lenses are Medically Nec-
essary. When a Members frames and/or lenses are
lost, stolen, or broken beyond repair, replacement
eyeglasses are covered up to two (2) pairs of identi-
cal substitute eyeglasses per Member per calendar
year for Members under the age of twenty-one (21)
one (1) pair of identical substitute glasses per Mem-
ber per calendar year for Members age 21 and over
provided the number of replacements have not ex-
ceeded Medicaid limits as listed. One year is defned
as 365 days from the date the frst pair of eyeglasses
(initial or subsequent) was ordered. Coverage shall
be provided only for Medically Necessary, non- de-
luxe frames and/or lenses determined by HPP to be
eligible for reimbursement.
Replacement of Lenses Only - Replacement of a cor-
rective lens(es), without frames, for one that is dam-
aged or broken is a beneft if that lens(es) is covered
by Medicaid and the replacement limits have not
been exceeded. A replacement lens(es) must be
an identical copy of the damaged or broken lens.
For periods greater than 24 months from the date
of the previous prescription when ordering subse-
quent lenses or complete eyeglasses, see Medicaid
diopter guidelines.
Replacement of Frames Only - Replacement of a
complete frame (front and temples) is a Medicaid
beneft only when the original frame is broken be-
yond repair, the prescription lenses remain usable,
and the replacement limits have not been exceed-
ed. The replacement frame must be an identical
replacement. If an identical frame is not listed as
a Medicaid beneft, the benefciary must select a
frame that is a covered beneft. The contractor bills
Medicaid for the complete frame. The vision provid-
er inserts the lenses into the frame and bills Medic-
aid for the dispensing service.
I. Phase II Cardiac Rehabilitation Services. Benefts are
limited to twenty-four (24) sessions in twelve (12)
weeks.
9.2 EXCLUSIONS
Coverage for services and products not specifcally
identifed by this Contract are not Covered
Services, including, but not limited to:
A. Services and supplies not provided by, or under the
direction of, the Members Primary Care Physician,
except Emergency Health Services and/or services
rendered by a Non-Afliated Provider after being
Appropriately Referred, or as otherwise stated in
this Contract.
B. Services and supplies to the extent not Medically
Necessary for the diagnosis and treatment of injury,
illness, or pregnancy.
C. Services and supplies not required to be provided
in accordance with the provisions of the Medicaid
Program.
D. Charges that are in excess of Reasonable Charges.
E. Dental Care and associated supplies, services, and
tests, except as specifcally provided in Section 8.15.
F. Cosmetic surgery and other services and products
for Cosmetic purposes, such as procedures to cor-
rect baldness or wrinkling. However this exclusion
would not apply to Medically Necessary Recon-
structive surgery.
G. Custodial or domiciliary care, Basic Care or house-
keeping provided on an inpatient, outpatient, or in-
home basis.
H. Examinations, reports or any other services related
to requirements or documentation of health status
for employment, licenses, insurance, travel, or for
educational or sports/recreational purposes.
I. Services for any injury or illness to the extent any
benefts, settlements, awards or damages are avail-
able under Workers Compensation, any insurance
plan or other third party payor, State or Federal leg-
islation, or any school or other public program sup-
ported in whole or in part by governmental funds.
Services for any injury or illness related to an acci-
dent involving an automobile or other motor ve-
hicle when the Member has an uncoordinated auto
insurance policy.
J. Services for which the Member is eligible under any
governmental program, or services for which, in
the absence of any health service plan or insurance
plan, no charge would be made to the Member.
K. Services for any injury or illness resulting from war,
or an act of war or service in the armed forces of any
country, to the extent coverage of such injury or ill-
ness is available through any governmental plan or
program.
L. Medical, surgical, or psychiatric procedures, treat-
ment or devices, pharmacological regimens (except
for antineoplastic drugs required to be covered in
accordance with Section 3406e of the Insurance
Code) and associated health care services, which
are considered Experimental in nature under ac-
cepted standards of practice. Something may be
considered by HPP to be Experimental if one of the
following circumstances applies:
1. FDA approval has not been granted at the time
of its use or proposed use.
2. It is the subject of an investigational new drug
or device application on fle with the FDA.
3. It is being provided as part of a Phase I, II, or III
clinical trial.
4. It is being provided under the supervision of an
Institutional Review Board.
5. It is being provided pursuant to experimental
or research protocol testing for factors such as
safety, efcacy, or toxicity.
6. Published literature indicates that further re-
search is needed to defne factors such as safety,
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HealthPlus Partners Subscriber Contract
efcacy, or toxicity.
M. Mental health services and supplies which are:
1. Rendered in connection with mental illness not
classifed in the International Classifcation of
Diseases of the World Health Organization, as
modifed by the U.S. Center for Health Statistics;
2. Extended beyond the period necessary for the
evaluation and diagnosis of mental retardation;
or
3. For mental diseases or illness which, according
to generally accepted professional standards,
are not usually amenable to favorable modifca-
tion.
N. Inpatient mental health services, inpatient and
outpatient substance abuse services, and intensive
outpatient program.
O. Vocational rehabilitation services.
P. Personal comfort or convenience items such as tele-
vision and telephone services.
Q. Any type of shoe supply for fexible fat feet or toe-
in, toe-out problems, except where there is a specif-
ic rigid deformity of the foot, or torsional problems
of the extremities, except when shoes are attached
to a brace.
R. Sex transformation surgery and all expenses in con-
nection with such surgery.
S. Infertility treatment, including but not limited to:
reversal of a voluntary sterilization, artifcial insemi-
nation, all forms of in vitro fertilization, gamete in-
trafallopian transfer, and zygote intrafallopian trans-
fer; transsexual surgery; all services related to surrogate
parenting arrangements; and all associated services
and preparatory treatment related to any of the above.
Drugs used specifcally for the purpose of treating in-
fertility are not a beneft.
Infertility services are not covered if one of the part-
ners has previously undergone surgical sterilization
or if one of the partners is menopausal or post-
menopausal.
T. Surgery and any other services or supplies for the
purpose of weight reduction or control except
when specifcally approved by HPP for severely
obese Members with high-risk co- morbidities.
U. Wigs, prosthetic hair, hair transplants or other pro-
cedures or supplies to enhance hair growth.
V. Court ordered tests, reports, or treatment, unless
otherwise covered by this Contract.
W. Care rendered while in police custody, unless au-
thorized by the Members Primary Care Physician.
X. Services or products provided by Convalescent
Homes, Homes for the Aged or Adult Foster Care
Facilities.
Y. Drugs, dietary and other supplements, articles, and
supplies provided on an outpatient basis which
are not specifcally listed in the HPP Medicaid for-
mulary. HPP may elect to cover and include certain
over-the-counter drugs on the HPP Medicaid for-
mulary based on recommendations made by our
Pharmacy and Therapeutics Committee.
Z. Ancillary Services provided as an adjunct to services
for which Health Care Benefts are not provided un-
der this Contract.
AA. Skilled Care provided on a twenty-four (24) hour ba-
sis in the home.
BB. Skilled Nursing Facility services that are considered
long term care under the Medicaid Program.
CC. Hearing Aids ordered prior to the Efective Date of
Coverage under this Contract and the additional
cost of an eyeglass type Hearing Aid or other Hear-
ing Aid with special features that are not Medically
Necessary over the conventional type of Hearing
Aid.
DD. Private duty nursing services.
EE. Routine foot care including, but not limited to, hy-
gienic care, treatment of corns, calluses or toenails.
FF. Charges associated with hypnosis, or acupuncture
services. GG. Services, products, or supplies which
are illegal.
HH. Charges for the completion of claim forms, inter-
est on late payments, or charges for failure to keep
scheduled appointments.
II. Medical expenses incurred by a Member who do-
nates an organ or tissue to a non-Member.
Medical expenses incurred by a non-Member who
donates an organ or tissue to a Member will only be
covered if the non-Member does not have coverage
for these services.
JJ. Services which are provided by individuals who are
not licensed/certifed under the Michigan Public
Health Code (or other similar code/statute of any
other state or governmental unit) or services which
are beyond the treating individuals licensing.
KK. Premarital exams or classes.
LL. Contact lenses, other than those required to be pro-
vided by the Medicaid Program.
MM. Services provided to the Member by: the Member,
immediate family members of the Member, or in-
dividuals that have the same legal residence as the
Member.
NN. Maternal Infant Health Program (MIHP) services.
OO. Behavioral health Prescription Drugs carved out
from Medicaid Health Plans and covered by MDCH.
PP. Medicare Part D Drugs are not a covered beneft for
Dual Eligible Members.
SECTION X
GENERAL CONDITIONS
10.1 NOTICE
Any notice required or permitted to be given by this
Contract shall be appropriately given if in writing and
either personally delivered, or deposited in the United
Page 46
HealthPlus Partners Subscriber Contract
States mail with postage prepaid and addressed to the
Member at the address of record on fle at the principal
ofce of HPP.
10.2 GOVERNING LAW
This Contract is made and shall be interpreted under the
laws of the State of Michigan.
10.3 ACCEPTANCE OF CONTRACT
It is acknowledged and agreed that the Members ex-
ecution of the Application form and/or use of the HPP
Identifcation Card shall be deemed to be his/her accep-
tance of this Contract.
10.4 ENTIRE CONTRACT
This Contract constitutes the entire understanding be-
tween HPP and Members, and, as of the Efective Date
of Coverage, supersedes all other like agreements.
10.5 WAIVER BY AGENTS
No agent or other person, except an ofcer of HPP, or
other authorized Committee, has authority to waive any
condition or restrictions of this Contract, or to bind HPP
by making promise or representation or by giving or
receiving any information. No change in this Contract
shall be valid unless evidenced by an endorsement or
Rider formally issued by HPP.
10.6 AMENDMENTS
This Contract shall be subject to amendment, modifca-
tion or termination in accordance with its provisions or
as required by law.
10.7 REINSTATEMENTS
HPP may reinstate this Contract after the Efective Date
of Termination without the execution of a new Ap-
plication or the issuance of a new Identifcation Card
or any notice to the Eligible Individual, other than the
unqualifed acceptance of an additional payment from
the Group. No such payment shall create any rights to
service for periods prior to the reinstatement date de-
termined by HPP, which shall become the Efective Date
of Coverage for all subsequent purposes hereof.
10.8 IDENTIFICATION CARDS
Identifcation Cards issued by HPP to Members are for
identifcation only. Possession of an Identifcation Card
confers no rights to Health Care Benefts not otherwise
available under this Contract.
10.9 POLICIES AND PROCEDURES
HPP may unilaterally adopt and change reasonable poli-
cies, procedures, rules, and interpretations to promote
the orderly and efcient administration of this Contract.
HPP reserves the right to review services, supplies, prod-
ucts and procedures for efcacy of use and quality to
determine if they should be available to HPP Members.
10.10 ASSIGNMENT
All rights of a Member to receive Health Care Benefts
are personal and may not be assigned. HPP may assign
this Contract to its parent corporation, HealthPlus of
Michigan, Inc., subject to any necessary regulatory ap-
provals.
10.11 PROVIDER DISCLAIMER
HPP assumes no responsibility for Physicians or other
Providers treating the Member, their competency, or
their acts or omissions.
10.12 TREATMENT BY NON-AFFILIATED PROVIDERS
This Contract shall not be interpreted to restrict a Mem-
bers decision to be treated by any Provider chosen by
the Member; provided, however, Health Care Benefts
may be limited or excluded if the provisions of this Con-
tract are not followed by the Member.
10.13 HEADINGS
The headings and titles of this Contract are for ease of
reference only, and shall not be interpreted to expand
the Health Care Benefts aforded.
10.14 SEVERABILITY
In the event that any section, or portion thereof, of this
Contract is held unenforceable or invalid by any compe-
tent adjudication, the validity and enforceability of the
remaining sections, or portions thereof, shall not be af-
fected thereby.
10.15 WAIVER
HPPs waiver or failure to enforce any section, or portion
thereof, of this Contract on any one occasion shall not
constitute a release of that section, or portion thereof,
or waiver of its terms on any future occasion.
10.16 RECOVERY OF PAYMENTS
HPP shall be entitled to recover payments from the Eli-
gible Individual and/or Eligible Dependent respecting
any and all claims payments made by HPP for services
rendered to the Eligible Individual and/or Dependent
after the Efective Date of Termination.
Page 47
HealthPlus Partners
Board of Directors
At least one-third of the people who
sit on the HealthPlus Partners Board of
Directors are elected from the HealthPlus
Partners members. The remaining Board
members are providers and members of
the business community. The entire Board
is elected by the members of HealthPlus
Partners. This allows members a voice in
how HealthPlus Partners provides health
care benefts to its members.
If you would like to serve on the
HealthPlus Partners Board, please call the
HealthPlus Partners Legal Department at
(810) 230-2168.
Other Important
Phone Numbers
HealthPlus Partners Customer Service
1-800-332-9161
Michigan Enrolls
1-888-ENROLLS (1-888-367-6557)
Transportation
1-888-676-1783
Michigan Department of Community
Health Benefciary Hotline
1-800-642-3195
HealthPlus Compliance
Fraud, Waste and Abuse Hotline
1-800-345-9956, option 4
Dental Services covered
by the State of Michigan
1-800-642-3195
MIBridges
www.mibridges.michigan.gov/access
1-888-642-7434
Fill in the following phone numbers
as a handy reference:
PCP Name
PCP Phone #
My Primary Hospital
My Case Workers Name
My Case Workers Phone #
Substance Abuse
Coordinating Agency
WIC Ofce
1-800-332-9161
Telecommunications Device for the Deaf
(TDD) 1-800-992-5070
healthplus.org
Flint 2050 S. Linden Road / Flint, MI 48532
Saginaw 5454 Hampton Place / Saginaw, MI 48604
HealthPlus Partners Service Area
As of January 1, 2005
HealthPlus Partners Service Area
NLDICAID PLAN