health plus handbook

7/27/2019 Health Plus Handbook

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2012 - 2013 HealthPlus Partners

Member Handbook


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This packet includes your:n Subscriber Contract

n Benefit Summary

n Transportation Pocket Card

HealthPlus Partners ID CardIf 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 fewdays, 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 office, or to the pharmacy, show your

HealthPlus Partners card and your green mihealth card.

If you have questions about your card, your benefits or how to access care, please call Customer

Service.

Provider DirectoryIf you would like a provider directory, please call Customer Service toll-free at 1-800-332-9161, TDD linefor 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 TransportationCall 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 includingyour 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 transportationservices 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 hearabout 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 youstay 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.


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IntroductionWelcome to HealthPlus Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2View us online at www.healthplus.org . . . . . . . . . . . . . . . . . . . . . . 2Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Your mihealth Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Your HealthPlus Partners Identification Card . . . . . . . . . . . . . . . . 2Choosing the Right Primary Care Physician (PCP) . . . . . . . . . . . 3Specialists as a PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4How to Choose or Change Your Doctor . . . . . . . . . . . . . . . . . . . . . 4Enrolling New Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

How to Use the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Canceling and Changing Appointments . . . . . . . . . . . . . . . . . . . . 4Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Leaving HealthPlus Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Your Health Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Services Not Covered by HealthPlus Partners . . . . . . . . . . . . . . . 6Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Out of Network Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7C o p a y s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7How to Access Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Pharmacy Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Prescription Copay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Prior Authorization/Step Therapy ............................ 8Mandatory Specialty Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . 8

V i s i o n S e r v i c e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Low Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Language Interpretation Services ........................... 9Member Materials in Other Formats .. . . . . . . . . . . . . . . . . . . . . . . . 9Utilization Case Management Program . . . . . . . . . . . . . . . . . . . . . 9Care Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Foster Care Chi ldren. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Transportation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Make the Most of Your Health Benefits . . . . . . . . . . . . . . . . . . . . .10

Childrens Special Health Care Services (CSHCS)How to Enroll in CSHCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Your HealthPlus Partners ID Card. . . . . . . . . . . . . . . . . . . . . . . . . . . .11Your CSHCS Health Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Additional Benefits for CSHCS Health Plan Members . . . . . . .13Services Not Covered by HealthPlus Partners but

Covered by the State Medicaid Program . . . . . . . . . . . . . . . .13Services Not Covered by HealthPlus Partners or

Covered by the State Medicaid Program . . . . . . . . . . . . . . . .13

Medicare/Medicaid MembersYour HealthPlus Partners ID Card. . . . . . . . . . . . . . . . . . . . . . . . . . . .14Choosing the Right Primary Care Physician . . . . . . . . . . . . . . . . .14

Your Medicare/Medicaid Health Benefits . . . . . . . . . . . . . . . . . . .15Turning 65? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Part B Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Part D Drug Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Womens HealthJanets Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17OB/GYN Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Having a Baby? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Childbirth Education Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Maternal Infant Health Program (MIHP) . . . . . . . . . . . . . . . . . . . .17Post-Partum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Women, Infants and Children (WIC)

Supplemental Food & Nutrition Program . . . . . . . . . . . . . . .18Get Tested for Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Dont Forget Your Pap Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18How to Detect Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Childrens HealthWell Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Lead Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Immunizations (Shots) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Colds and Sore Throats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Mens HealthProstate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Health and WellnessHealth and Wellness Information ...........................20Health and Wellness Online. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Stop Smoking Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Weight Management Programs and Services . . . . . . . . . . . . . .20Health and Wellness Self-Help Information . . . . . . . . . . . . . . . . .20HealthQuest Toll Free Health Information Line . . . . . . . . . . . . .20

Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20HealthQuest Perks Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Disease ManagementA s t h m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

MiscellaneousNew Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23If You Have Other Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23If You Receive a Bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23If You Move or Lose Medicaid Eligibility . . . . . . . . . . . . . . . . . . . . .23

Request for Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Member Satisfaction Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24There are Two Stages of Grievances . . . . . . . . . . . . . . . . . . . . . . . .24State Fair Hearing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . .25Patient Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Medical Decisions/Advanced Directives . . . . . . . . . . . . . . . . . . . .27Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Explanation of Benefits (EOB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28HealthPlus Partners Subscriber Contract. . . . . . . . . . . . . . . . . . . .29HealthPlus Partners Board of Directors . . . . . . . . . . .Back CoverOther Important Phone Numbers . . . . . . . . . . . . . . . .Back CoverHealthPlus Partners Service Area . . . . . . . . . . . . . . . . .Back Cover

Page 1Table of Contents

Table of Contents


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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/orneed 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 theDeaf (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!

We are pleased to have you as a member of HealthPlus Partners. We

are a Medicaid health plan. We have doctors and other providersto give you the services you need. HealthPlus Partners offersmembers a wide range of health care benefits.

HealthPlus of Michigan became a corporation in 1977. HealthPlus Partnersbecame a wholly-owned subsidiary corporation of HealthPlus of Michiganin 2003. We are a non-profit company. We are licensed by the State ofMichigan. The federal government has qualified us as a health maintenanceorganization. We want to help you make the most of your health carebenefits. We believe in quality care. Welcome to HealthPlus Partners!

How to Use this BookHealthPlus Partners covers multipleMedicaid members. Everything in this

book applies to all members except for thesections specifically identifying benefits

for key groups. We hope this helps provideclarity for the benefits of each group. If

you have questions, please call customerservice toll free at 1-800-332-9161.

View us online at

www.healthplus.orgCheck us out on our website. The site tellsyou about our doctors, programs and

services. You can also find out about yourrights and responsibilities as a HealthPlus

Partners member. The site has a mapof our service area. It also provides lotsof useful consumer health information.

There is a link to the National Committeefor Quality Assurance (NCQA). NCQA is

an independent company that checksmanaged care plans across the country to

improve the quality of care.

Customer ServiceWe want to help you make the most

of your benefits. If any of the followingshould happen, call Customer Service

(24 hours a day, 7 days a week) toll free at1-800-332-9161.

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 bycontacting your case worker.

Your mihealth CardThe State of Michigan issues each

Medicaid, Medicaid Childrens SpecialHealth Care Services (CSHCS) or Medicaid/

Medicare beneficiary a permanentMedicaid ID card called a mihealth card.Your mihealth card provides the following

information:

1. Beneficiary ID number

2. Beneficiary name

This card is to be used for services notcovered by HealthPlus Partners as listed on

page 6 of this handbook. You should alsoshow this card with your HealthPlus

Partners ID card when you receive servicesIf this card is lost or stolen, please call the

State of Michigan Beneficiary helpline at1-800-642-3195.

Your HealthPlus PartnersIdentification CardYour identification card lists you as a

member who is covered by HealthPlusPartners. If any information on the card isincorrect, please call Customer Service (24

hours a day, 7 days a week) at1-800-332-9161 or visit us atwww.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.


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Page 3Introduction

Partners card and a green mihealth (My

Health) card from the State. You will needboth cards to get services. If you lose

your HealthPlus Partners card, or if theinformation 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. CoverageIdentifies your benefit level

3. Effective DateThe date your current coverage became

effective

4. Recipient ID NumberMember identification number

5. Member NameMember name

6. Primary Care Physician (PCP) NameName of members PCP

7. PCP TelephonePCP office telephone number

8. HospitalHospital your doctor uses and where

you will be sent, if needed

Always show bothof your cards when youreceive care. Do not allow anyone else touse your identification 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 identification card, orrequire additional cards, please contact

Customer Service or visit us on the Web at

www.healthplus.org.

Your identification card is also important

if you are hospitalized. Please notifyHealthPlus Partners in the event that a

hospitalization occurs. The back of yourcard has the telephone number to call.

Always have your card handy when youcall or visit HealthPlus Partners. This helpsus serve you quickly and efficiently.

Choosing the Right PrimaryCare Physician (PCP)You must choose a HealthPlus Partners

Primary Care Physician (PCP) as your maindoctor. When choosing a doctor, think

about what is important to you and yourfamily. You may want to choose a doctorclose to your home or your childrens

school. You may choose a doctor in familypractice, internal medicine, a pediatrician

for your child or a doctor at a clinic. Ifyou choose a pediatrician as your childs

PCP, you do not need a referral for theseservices. All of these doctors provideprimary care, but in different ways.

Family Practice doctorsgive health care

to male and female patients of all ages andhealth problems. They can also be yourchilds pediatrician. Some deliver babies

and take care of womens health needs.

Internists give care to adults with both

regular health care needs and specialproblems.

Pediatricianstake care of babies, children

and teenagers.

Federally Qualified Health Centers

(FQHCs) give care to male and femalepatients of all ages and health problems.

They also provide other services notcovered by HealthPlus Partners, but arecovered by the State such as dental care.

You may go to any FQHC in any countywithout a referral from your PCP. You may

also choose to get your services from oneof 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)

Clinicsare staffed with resident doctorswho must spend an extra three to five

years in training for their specialty. Boardcertified doctors supervise them. When

you choose a clinic as your doctor, youwill 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 COUNTYn Mott Childrens Health Center-

Northwestern HS

n Mott Childrens Health Center-

Beecher/Dolan MS

n Mott Childrens Health Center

SAGINAW COUNTYn 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 HealthDepartment-Durand MS/HS

When you pick your doctor, you agree touse the same specialists and hospital your

doctor uses. It is important to have a goodrelationshipwith your doctor so he or she

knows about your health.

RXBIN 610011 RXPCN 23050

RECIPIENT NUMBER1234567890

RECIPIENT NAME

JOHN DOE

PCP NAME/TELEPHONE#

DR. SMITH

Hometown Regional Medical Center

EFFECTIVE DATEOF COVERAGE

01/01/11

GROUP

#987654

(810) 750-6060

A product of HealthPlus of Michigan, Inc.

BP = 2.

3.

1.

7.

4.

5.

6.

8.


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You may change your PCP for any reason.The change will be effective on the first

day of the month after you make yourrequest. A customer service representative

can answer any questionsyou may

have about the doctor you choose or anydoctor you will see. If you want to know if adoctor is male or female, where they went

to medical school, or if you have any otherquestions, call 1-800-332-9161.

Local Health Departmentsare alsoavailable to provide some health careservices. If available in your county, you

may receive primary care from theselocations without prior authorization.

Specialists as a PCPSpecialists are doctors who focus on

one area of medicine or one part of thebody. Some people have chronic healthconditions and need to see a specialist a

lot. In such cases, it may be better for thespecialist to be your main doctor and act

as your PCP. If this occurs, our medical staffwill make that decision with you.

How to Choose or ChangeYour Doctor

The provider directory gives you the

names, locations and specialties of doctorswho are taking new patients in yourcounty. 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. Theaccepting status of each doctor is listedafter the hospital they use. The accepting

status for HealthPlus Partners doctors islisted below:

Yesmeans you can choose this doctor.

Conversionsmean you can choose thisdoctor if you are already a patient of thisdoctor when you get HealthPlus Partners.

Families Onlymeans you can choose this

doctor if everyone in your family does.

Newborns Onlymeans you can choose

this doctor for your baby if your baby isone year old or younger. If your other kidsalready see this doctor, and they now have

HealthPlus Partners, they can stay with thisdoctor.

Over 50means you have to be 50 yearsold or older to choose this doctor.

Over 65means 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 directoryonline at www.healthplus.org. If you

would like a printed copy of the providerdirectory, please call Customer Service.

You can change doctors at any time. Thechange will be effective on the first day ofthe month after you make your request. If

you have any questions aboutchoosing adoctor,or the doctor youve been given,

please call Customer Service.

Enrolling New DependentsIf someone new is added to your case,you must call Michigan ENROLLS at1-888-ENROLLS to choose HealthPlus

Partners as your health plan. If you have ababy, the baby will automatically become

our member. Please call us with the nameof your new baby and his or her new ID

number as soon as you receive it.

Medicaid EligibilityRe-Determination

On an annual basis, Medicaid enrolleesmust go through an eligibility re-determination. This process is done by the

State through your caseworker and looksto see if you still qualify for Medicaid. TheState will send you notice of this time with

any needed paperwork. It is importantthat you complete them and turn them in

to your caseworker. This will help to keepyour Medicaid benefits andHealthPlus as

your health insurance plan.

How to Use the PlanYou will get most of your services fromyour PCP. If needed, your PCP will referyou to a specialist. Your PCP will set up all

of your health services including hospitalstays. 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 IDcard. Describe why you need to see the

doctor. The doctors assistant may giveyou an appointment. He or she may also

suggest that you try something at homeor go to another doctor. Be ready for your

appointment.

n Write down how you are feeling.

n Write down questions you want toask.

n Write down the names of the

medicines you are taking.

n Ask questions about your doctorsdirections.

Canceling and ChangingAppointmentsIf you need to change or cancel yourappointment, please call your doctor the

day before. Many doctors will discharge

you as their patient for multiple no showappointments.

No shows are appointments you do not

keep and do not notify the doctor priorto your appointment that you will not be

there. Calling ahead of time allows yourdoctor to see someone else who mayneed services.

ReferralsYour PCP is responsible for your health

care. Your PCP will decide if you needto see a specialist. If you are referred

to a specialist, you will get a copy of thereferral. The referral will tell you how many

visits you get and what services you willhave. If you run out of visits, call your PCP.

RestrictionsYou may not be able to go to somedoctors. Most doctors refer their patients

to specialists who are part of their healthsystem. In most cases, your PCP will tell

you which doctors you may see.

There are some services that need

approval by HealthPlus Partners beforeyou can receive the service. Whenapproval is required, your doctor and/or a

case manager will coordinate the process.

Introduction

Page 4 Introduction


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Your Health Benefits

Page 6 Your Health Benefits

Leaving HealthPlusPartners?You receive a lot of information from the

Department of Human Services about

your health care benefits. Its a lot ofinformation that can be confusing. Eachmonth, we receive an enrollment file from

the State that tells us those members thatare being termed from our plan at theend of the month. We only have one week

between the time we find out and theend of the month.. HealthPlus will work

to notify you if we have been told by theState 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, orn Go online at https://www.mibridges.

michigan.gov/access

This will tell you what is happening with

your case. We hope you will chooseHealthPlus Partners as your health plan

again.

Services Not Covered byHealthPlus Partners

Services Not Covered by HealthPlusPartners But Covered by the StateMedicaid Program

We do not pay for these services. Wewould be happy to help you contact the

right agency.

1. Long-term basic care servicesContact HealthPlus Partners case

management for assistance

2. Substance abuse servicesContact your local coordinating

agency

3. Inpatient mental health servicesContact your local community mental

health agency

4. Routine dental careSee any dental provider who accepts

Medicaid

5. Transportation for care or servicesnot covered by HealthPlus PartnersContact your case worker

6. Mental health after 20 outpatientvisitsContact your local community mental

health agency

7. Outpatient partial psychiatrichospital careContact your local community mental

health agency

8. Personal care or home help servicesContact your case worker

9. Some school services billed by

intermediate school districtsContact your local school district

10. Some developmental disability careContact your local community mental

health agency

11. Home and community-based waiver

servicesContact your case worker

12. Intermittent or short-term

restorative or rehabilitative services(in a nursing facility), after 45 daysContact the State Beneficiary Help Line

13. Traumatic brain injury programservicesContact the State Beneficiary Help Line

14. Substance abuse medications,antipsychotic medications

and other behavioral healthmedications, medications for HIV/AIDS, medications to treat bleeding

disorders and some rare metabolic

conditions.15. Maternal Infant Health Program

(MIHP) ServicesContact 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 HealthPlusPartners or by the State MedicaidProgram

We do not pay for these services nor doesthe State Medicaid Program. You will have

to pay for these services:

1. Elective abortions and related

services (covered only if given tosave the life of the mother or to end

a pregnancy resulting from rape orincest)

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-coveredservices.

Urgent Care

In the HealthPlus Partners ServiceAreaYou dont have to use the emergency

room when you are sick and your doctorsoffice is closed. We have many after hours

clinics that will help you. If you cannot waituntil the next day to see your doctor, call

his or her telephone number to reach the

answering service or doctor on call. Theywill tell you which after hours clinic to use.

If you get urgent care services from an out

of network provider without authorizationyou may have to pay the bill.

Outside of the HealthPlus PartnersService AreaIf 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 decidewhat to do.

Examples of some types of urgentproblems 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, youwill have a copay and you may have to pay

the bill.

Emergency Care

In or outside of the HealthPlusPartners Service AreaCall your PCP if you are sick. If the office is

closed, you can reach your doctor throughthe answering service at his or her office


11/52

Page 7Your Health Benefits

number. If it is an emergency, they willcontact 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 transportationfor you. If you are admitted to the hospital,have someone call HealthPlus Partners

as soon as possible. The number is on theback of your HealthPlus Partners ID card.

This will help us arrange to pay for anyservice.

Do not use the emergency room or afterhours center for illness that can be treated

by your doctor during office hours.

Remember, if you go to the emergency

room for a non-emergency service, youmay 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 problemsn 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 gettingbleach or objects in your eyes, orbeing hit in the eye with something.

Out of Network ServicesHealthPlus Partners has a large providernetwork covering all specialty areas.However, there may be times when the

services you need are not available withinour network. If this happens, your PCP will

refer you to a hospital or provider that canaddress your medical needs. HealthPlus

Partners will pay for covered servicesreferred by your PCP. If you do not have areferral, you may have to pay the bill.

HealthPlus Partners covers services at yourdoctors hospital. If you need emergency

treatment and cant get to your doctorshospital, please go to the nearest

emergency room. HealthPlus Partners will

pay for the visit.

CopaysAll authorized and covered servicesprovided by HealthPlus are covered in full.

Attention Dual Eligibles (Medicare/Medicaid) MembersHealthPlus Partners does not cover Part D

drugs. These are covered by your Part Dplan. If you do not have one, you will be

responsible for those drugs. HealthPlushas suggestions on ways to reduce the

cost of these drugs if you do not have aPart D plan. Call our Customer Service.

Behavioral Health ServicesIf youre depressed or need counselingtoget through a difficult time, you can get

help. For behavioral health services youcan choose any participating counselor,

but you may want to ask your PCP orHealthPlus Partners toll free at 1-800-555-5025 for help in selecting a counselor.

Your local Community Mental HealthDepartment will help you if you need to

stay in the hospital because of a mentalhealth issue. Look in the telephone

book for the Community Mental HealthDepartment in your county.

Durable MedicalEquipment (DME)Durable Medical Equipment (DME)includes supplies and equipment needed

for medical purposes to assist in your

health care needs. DME supplies includethings like:

n Diabetic supplies

n Asthma supplies

n Breathing supplies

n Blood pressure cuffs

n Diapers

n Wheelchairs

n And many more items

HealthPlus Partners has contracted DMEvendors that participate. Some supplies

can be delivered directly to your home.Call Customer Service if you have any

questions.

How to Access HospitalServicesWhen you select a PCP, you agree to use

his or her hospital affiliation. Each PCP isaffiliated with a specific hospital system.

This is the hospital your PCP will use forinpatient care or other services provided at

a hospital. Your PCP will direct your healthcare services provided in the hospital.

Pharmacy ManagementFor prescriptions, you must use a

participating HealthPlus Partnerspharmacy. Prescriptions should be writtenby 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 drugsrecommended by HealthPlus Partners.

There are many drugs on this list for yourdoctor to choose from.

Your doctor must have our okay to order:

n Brand name drugs when a generic is

availablen 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 drugsThese drugs have the same amount of

active medicine as the brand name drugand meet the same standards. When a

company creates a new drug, it is called abrand. That company is the only companythat can make and sell that drug until

the patent for the drug expires. Once thepatent expires, another company can

produce the drug under a different name.In order to do so, the drug must have the

same strength, dosage, ingredients andquality as the brand drug. The new drug isthen 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 thetypes of drugs that need approval.


12/52


13/52

Language InterpretationServicesIf you need a language or deaf interpreter

to go to your doctors appointment, call

STAT EMS at 1-888-676-1783 at least 24hours prior to your appointment and theywill make the needed arrangements. This

allows us to help set up the service so youare ready for your doctors appointment. Ifyou need language/translation assistance

for inquiries on benefits, providers, filing acomplaint, etc., you may contact Customer

Service Staff at 1-800-332-9161, Mondaythrough Friday, 8 a.m. to 6 p.m. TDD users

please call 1-800-992-5070.

Member Materials in OtherFormatsWe want to meet the special needs of ourmembers. Member materials are available

in other languages and formats free ofcharge. Please call us to request copies.

Utilization CaseManagement ProgramIf you have special medical needs, theutilization case management program

at HealthPlus Partners can help you. A

HealthPlus Partners social worker or nursecase manager will work closely with you

and your doctor to develop a treatmentplan 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, call1-800-332-9161. This is a free call.

If you call after our office is closed, the casemanager will call you back the next day.

Care Management ProgramWe want to make sure that you receivequality health care. We work with our

providers to:

n make sure that we know about all

your hospital stays and the servicesthat you may receive

n make sure that you receive anyservices you need after you leave the

hospital

n make sure that you receive casemanagement services if needed

At HealthPlus Partners, we promote

quality health care.

Foster Care ChildrenThe State requires children enrolled in

foster care to have a well child (ESPDT)physical and mental health screeningwithin 30 days of entering foster care.

Please call your doctor to set up yourappointment. Our case managers are here

to help. You can also call Customer Serviceif you need assistance.

Transportation ProgramHealthPlus has contracted with STATEMS to provide transportation services.

Representatives are available 24 hours/7days a week to schedule your services.

This includes meals & lodging, andinterpretation services for eligible

HealthPlus Partners members. To scheduleservices call toll free 1-888-676-1783. Ifyou need a ride to any covered HealthPlus

Partners medical service, call us toll freeat 1-888-676-1783. For transportation

requests you will be transported toyour health care providers office 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 requestedservices and the referral is in the

HealthPlus Partners system forservices requiring a referral.

n The request for transportation

has been made according to thetransportation guidelines.

These are the questions you will be asked:

n What is your first 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 theappointment?

n What is the name of the doctor youare seeing?

n What is this doctors office address?

STAT EMS will follow HealthPlus Partnerstransportation policy and guidelineslisted on the next page.

Meals & LodgingMeals & Lodging are provided whenthere is an overnight stay at a hospital for

a HealthPlus Partners member that is 50miles or more away from your home.

This benefit is provided to one (1) parentor guardian of a minor child or one spouse

or significant other of an adult for shortterm assistance.

These services should be scheduled inadvance with STAT EMS. Contact them torequest these services..

Guidelines1. You must call 1-888-676-1783 to

request services.

2. Requests for bus passes and mileagereimbursement vouchers must be

called in three to five business daysbefore your scheduled appointment.

3. Requests for cab service, if available

in your county, should be called in24 hours before your scheduled

appointment. Cab services are formembers with special needs, for

senior citizens or in special situations.All requests, including urgentrequests, will be verified with your

doctor.

4. Requests for meals & lodging should

Page 9Your Health Benefits


14/52

be scheduled at least 24 hoursin advance through STAT EMS to

allow time to complete the neededarrangements..

CancellationsIf you need to cancel a scheduled cab ride,you must call HealthPlus Partners two

hours before your appointment. If youdont, the ride will be considered a noshow.

No Show AppointmentsNo show appointments are when cab

rides are scheduled for you, but:

n You didnt give us enough time to

cancel the ride, if necessary

nYou didnt use the cab when it arrivedto take you to your appointment

n The cab was sent, then you cancelledthe ride

Page 10 Your Health Benefits

Your Health Benefits

Transportation SanctionsAfter your first no show, you will receive aletter from HealthPlus Partners with a copy

of the transportation policy. If you have asecond no show, you will no longer be

able to use cab service. You will only begiven bus passes. You will receive a letterfrom HealthPlus Partners if this happens.

Make the Most of YourHealth Benefits

Stay HealthyThere 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 smokingn Say no to drugs and alcohol

n Practice safety

Eat RightThe local health department can

help you and your family with yournutritional needs. To find out more aboutthese programs, call your local health

department.


15/52

Childrens Special HealthCare Services (CSHCS)Childrens Special Health Care Services

(CSHCS) is a State of Michigan program

that serves children, youth and someadults with special health care needs.

HealthPlus Partners is pleased to offer

health care services to these families. Wewill work with the families to coordinate

the care, address pharmacy and medicalsupply needs ordered by their variousdoctors including transportation

when needed for services covered byHealthPlus Partners. CSHCS members

can look forward to the same level of careHealthPlus Partners provides to all of its

members. It is this that we welcome you toour HealthPlus family!

How to Enroll in CSHCSCSHCS covers more than 2,700 medicaldiagnoses. CSHCS helps persons with

chronic health problems. There areadditional benefits provided that are listed

in the Your Benefit section of this book.

To join, children and some adults must

have a qualifying condition. Someexamples of medical conditions include:

n Cancern 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 Conditionsn 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 theneeded materials to MDCH to determine

eligibility for this program. Contact

HealthPlus Customer Service toll free at1-800-332-9161 for more information.

Your HealthPlus Partners

Identification CardYour identification card lists you as amember who is covered by HealthPlus

Partners. If any information on the card isincorrect, please call Customer Service (24

hours a day, 7 days a week) at1-800-332-9161 or visit us at

www.healthplus.org with the correctinformation as soon as possible.

Each member will get a HealthPlusPartners card and a green mihealth (My

Health) card from the State (see page 2).

You will need both cards to get services. Ifyou lose your HealthPlus Partners card, or

if the information changes, call us toll freeat 1-800-332-9161.

Your HealthPlus Partners card provides thefollowing information:

1. Group Number

Indicates group or individual coverage

2. CoverageIdentifies your benefit level

3. Effective DateThe date your current coverage became

effective

4. Recipient ID NumberMember identification number.

5. Member NameMember name

6. Primary Care Physician (PCP) Name

Name of members PCP

7. PCP TelephonePCP office telephone number

8. HospitalHospital your doctor uses and where

you will be sent, if needed.

9. CSHCS

Identifies you as a HealthPlus Partners

Childrens Special Health Care Services

Member.

Always show bothof your cards when you

receive care. Do not allow anyone else touse your identification card. Improper use

of your card is considered fraud and canresult in the cancellation of your healthcare coverage with HealthPlus Partners. If

you lose your identification card, or requireadditional cards, please contact Customer

Service or visit us on the Web atwww.healthplus.org.

Your identification card is also importantif you are hospitalized. Please notifyHealthPlus Partners in the event that a

hospitalization occurs. The back of yourcard has the telephone number to call.

Always have your card handy when youcall or visit HealthPlus Partners. This helps

us serve you quickly and efficiently.

Childrens Special Health Care Services


RECIPIENT NUMBER1234567890

RECIPIENT NAME

JOHN DOE

PCP NAME/TELEPHONE#

DR. SMITH



01/01/11

GROUP

#98765C

(810) 750-6060


CSHCS

BP = A3

Page 11Childrens Special Health Care Services

9.

2.

3.

1.

7.

4.

5.

6.

8.


16/52

Your CSHCS Health Benefits

A brief summary of your benefits 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

benefits.

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 Benefits

Here are your benefits: Here is how to use them:

Primary Care Services

Office visits

Well child visits includes the developmental/behavioral healthBaby shots

Lab and X-raysSpecialist services okayed by your PCP

Medically necessary weight loss services

End Stage Renal DiseaseMaternity care

Pre and post-natal servicesCertified 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 ServicesSemi-private roomDoctor Surgery care Maternity careDiagnostic careLab and X-ray Drugs and supplies

Organ and tissue transplants


Outpatient Hospital Services

Lab and X-raysOutpatient surgeryDiagnostic testing


Emergency CareMedical careAmbulance

Go to nearest emergency room or call 911

Urgent Care After Hours Call your PCP and/or go to an After Hours Clinic

Pharmacy ServicesPrescription drugs Some over-the-counter items

Family Planning Services

ExamBirth 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


Hearing and Speech

Diagnostic servicesHearing aids covered for members under the age of 21

Hearing aid batteries

Your Doctor will arrange for your care

Mental Health ServicesTwenty 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 yearsGlasses 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


Other Services

Home health careChiropractic servicesPodiatrist servicesOral 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 classesCertified pediatric and nurse practitioner services

Out-of-state servicesHospice services Midwife servicesTreatment for communicable diseases

Your PCP will arrange for your care when needed

assessment


17/52

Additional Benefits forChildrens Special HealthCare Services Health PlanMembers

These are benefits covered either through

FFS Medicaid using your green mihealth

card or by calling the agency listed below

1. Help form your Local Health

Departmentwith:l Community resources schools,

community mental health,financial support, childcare, Early

On, and the Women Infants andChildren (WIC) program

l Transitioning to adulthooldl

Orthodontian Only or specific CSHCS

qualifying diagnosis such asCleft Palate/Cleft Lip

n Medically necessary, related tocondition

n Not for cosmetic purposesl Respite

n CSHCS covers 180 hours of

respite care annually when abeneficiary requires skilled nurs-

ing and a CSHCS nurse consul-tant determines appropriate.

2. Help from theFamily Center forChildren and Youth with Special

Health Care Needsl CSHCS Family Phone Line a toll

free phone number (1-800-359-3722) available Monday throughFriday from 8 am to 5 pm

l Parent-to-parent support networkl Parent/Professional training

programsl Financial help to go to conferences

about CSHCS medical conditionsand Relatively Speaking, a confer-

ence for siblings of children withspecial needs.

3. Help from the Childrens Special

Needs(CSN) Fund. The CSN Fundhelps CSHCS families get items not

covered by Medicaid or CSHCS. Tosee if you qualify for help from the

CSN Fund, call 517-241-7420.

Examples include:

l Wheelchair rampsl Van lifts and tie downs

l Therapeutic tricyclesl Air conditionersl Adaptive recreational equipmentl Electrical service upgrades for

eligible equipment

Services Not Coveredby HealthPlus PartnersBut Covered by the StateMedicaid ProgramWe do not pay for these services. We

would be happy to help you contact theright agency.

1. Long-term basic care services ContactHealthPlus Partners case management

for assistance

2. Substance abuse servicesContact your local coordinating agency

3. Inpatient mental health servicesContact your local community mental

health agency

4. Routine dental careSee any dental provider who accepts

Medicaid

5. Transportation for care or servicesnot covered by HealthPlus PartnersContact your case worker

6. Mental health after 20 outpatientvisits

Contact your local community mental

health agency

7. Outpatient partial psychiatric hospitalcareContact your local community mental

health agency

8. Personal care or home help servicesContact your case worker

9. Some school services billed byintermediate school districtsContact your local school district

10. Some developmental disability careContact your local community mental

health agency

11. Home and community-based waiverservicesContact your case worker

12. Intermittent or short-term restorativeor rehabilitative services (in a nursing

facility), after 45 daysContact the State Beneficiary Help Line

13. Traumatic brain injury programservicesContact the State Beneficiary Help Line

14. Substance abuse medications,antipsychotic medications

and, other behavioral healthmedications, medications for HIV/

AIDS, medications to treat bleedingdisorders and some rare metabolicconditions

15. Maternal Infant Health Program(MIHP) ServicesContact your local MIHP provider or

HPP for assistance in locating one near

you.

16. OrthodontiaUse your mihealth card to access these

services.

These are covered by the State of Michiganthrough your mihealth card.

Services Not Covered byHealthPlus Partners orby the State MedicaidProgramWe do not pay for these services nor doesthe State Medicaid Program. You will have

to pay for these services:

1. Elective abortions and relatedservices (covered only if given tosave the life of the mother or to end

a pregnancy resulting from rape orincest)

2. Acupuncture

3. Experimental/investigational drugprocedures or equipment

4. Elective cosmetic surgery

5. Any services not medically necessary

6. Treatment for infertility

Page 13Your CSHCS Health Benefits


18/52

Medicare/Medicaid Members


RECIPIENT NUMBER

1234567890

RECIPIENT NAME

JOHN DOE

PCP NAME/TELEPHONE#

DR. SMITH



01/01/11

GROUP

#98765D

(810) 750-6060


Medicare/MedicaidMember

BP = A1

Medicare/MedicaidMembersMedicare/Medicaid members sometimes

referred to as Dual Eligibles can now

remain enrolled with HealthPlus as long as:

1. You are receiving both Medicare andMedicaid benefits,

2. You have HealthPlus MedicareAdvantage, or

3. You have Fee -For-Service Medicare

(straight Medicare).

Fee-For-Service Medicare means you have

to use your traditional red, white and blueMedicare card for your Medicare benefits.You would not be part of any health plan

for your Medicare benefits.

Your HealthPlus PartnersIdentification CardYour identification card lists you as amember who is covered by HealthPlus

Partners. If any information on the card isincorrect, please call Customer Service (24

hours a day, 7 days a week) at1-800-332-9161 or visit us at

www.healthplus.org with the correctinformation as soon as possible.

Each member will get a HealthPlusPartners card and a green mihealth (MyHealth) card from the State (see page 2).

You will need both cards to get services. Ifyou lose your HealthPlus Partners card, or

if the information changes, call us toll freeat 1-800-332-9161.

Your HealthPlus Partners card provides thefollowing information:

1. Recipient ID Number

Member identification number.

2. Effective Date

The date your current coverage

became effective.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 office telephone number.

7. Hospital

Hospital your doctor uses and whereyou will be sent, if needed.

8. Coverage

Indicates your benefit package

9. Medicaid/Medicare Member

Identifies you as a HealthPlus PartnersMedicare/Medicaid Member.

Always show both of your cards when you

receive care. Do not allow anyone else touse your identification card. Improper useof your card is considered fraud and can

result in the cancellation of your health

care coverage with HealthPlus Partners.If you lose your identification card, orrequire additional cards, please contact

Customer Service or visit us on the web atwww.healthplus.org.

Your identification card is also importantif you are hospitalized. Please notifyHealthPlus 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 helpsus serve you quickly and efficiently.

Choosing the Right PrimaryCare Physician (PCP)You must choose a HealthPlus Partners

Primary Care Physician (PCP) as your maindoctor. When choosing a doctor, thinkabout what is important to you and your

family. You may want to choose a doctorclose to your home or your childrens

school. You may choose a doctor in familypractice, internal medicine, a pediatrician

for your child or a doctor at a clinic. If

you choose a pediatrician as your childsPCP, you do not need a referral for these

services. All of these doctors provideprimary care, but in different ways.

We will work to make sure the PCP youhave listed for Medicare is also the same

PCP for Medicaid.

Family Practicedoctors give health care

to male and female patients of all ages andhealth problems. They can also be your

childs pediatrician. Some deliver babiesand take care of womens health needs.

Internistsgive care to adults with bothregular health care needs and special

problems.

Federally Qualified Health Centers

(FQHCs) give care to male and femalepatients of all ages and health problems.

They also provide other services notcovered by HealthPlus Partners, but are

covered by the State such as dental care.You may go to any FQHC in any countywithout a referral from your PCP. You may

also choose to get your services from one

of the FQHCs listed below by choosingthem as your PCP:

n Hamilton Family Health Center

(Genesee County)

n Health Delivery Inc.(Saginaw, Bay, and Shiawassee

Counties)

Clinicsare staffed with resident doctors

who must spend an extra three to fiveyears in training for their specialty. Board

Page 14 Medicare/Medicaid Members

continues on page 16

9.

8.

2.

4.

6.

1.

3.

5.

7.


19/52

Your Medicare/Medicaid Health Benefits

Here are your benefits: Here is how to use them:

Primary Care Services

Office visits

Well child visitsBaby shots

Lab and X-raysSpecialist services okayed by your PCP

Medically necessary weight loss servicesEnd Stage Renal Disease

Maternity care

Pre and post-natal servicesCertified nurse midwife services

Call your PCP for an appointment


Go to your PCP or any in-plan OB/GYN

Inpatient Hospital Services

Semi-private roomDoctor Surgery care Maternity careDiagnostic careLab and X-ray Drugs and supplies

Organ and tissue transplants


Outpatient Hospital Services

Lab and X-raysOutpatient surgeryDiagnostic testing


Emergency CareMedical careAmbulance

Go to nearest emergency room or call 911

Urgent Care After Hours Call your PCP and/or go to an After Hours Clinic

Pharmacy ServicesPrescription drugs Some over-the-counter items

Family Planning Services

ExamBirth 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


Hearing and Speech

Diagnostic servicesHearing aids covered for members under the age of 21

Hearing aid batteries


Mental Health ServicesTwenty 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 yearsGlasses 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


Other Services

Home health careChiropractic servicesPodiatrist servicesOral 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 classesCertified pediatric and nurse practitioner services

Out-of-state servicesHospice services Midwife servicesTreatment for communicable diseases

Your PCP will arrange for your care when needed

A brief summary of your benefits are listedon this page. You must see your PCP or be

referred for care except as otherwise statedin this handbook. Please refer to your

Subscriber Contract for a more detaileddescription of your benefits.

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 15Your Medicare/Medicaid Health Benefits


20/52


21/52

Womens Health

Janets LawThere is a law called the Womens Health

& Cancer Rights Act of 1998. This Act isalso known as Janets Law.

Your HealthPlus Partners SubscriberContract explains the medical and

surgical benefits in connection with amastectomy as provided by this Act. If

you have had a mastectomy and wish toelect breast reconstruction in connection

with the mastectomy, please note that thefollowing coverage is available to you.

1. Reconstruction of the breast onwhich the mastectomy has been

performed;

2. Surgery and reconstruction of

the other breast to produce asymmetrical appearance;

3. Prostheses, if prosthetic devices arelisted as a covered service in your

Benefit Rider; and

4. Care for physical complicationsfrom all stages of the mastectomy,

including lymphedemas.

The above described coverage must beprovided in a manner determined in

consultation with you and your attendingphysician.

Finally, please note that the abovedescribed coverage is subject to anyapplicable copays as provided in your

Subscriber Contract.

If you have any questions, please callCustomer Service at 1-800-332-9161.

Womens Health ServicesYou do not need a referral to see an in-planOB/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-planOB/GYN doctor, or call Customer Servicetoll-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 donot need a referral for this service. Newmembers who are pregnant at the time

of enrollment with HealthPlus Partnersare 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 youcan 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 checkto make sure that both you and the

baby are healthy.

2. Dont smoke, drink alcohol or dodrugs. Your baby can be affected by

almost everything that you eat ordrink.

3. Eat healthy foods. Try green leafy

vegetables that are high in folic acid.These foods will help your body staystrong. It also helps your babys brain

develop well.

4. Practice safe sex. Sexually transmitteddiseases 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 afterpregnancy:

HealthPlus Partners has lots of providers tochoose from. You may also see a certified

nurse midwife for prenatal care. Please callCustomer Service at 1-800-332-9161 if youneed assistance.

State of your

pregnancy

When to see your

doctor

Before 14 weeks (or assoon as you think you maybe pregnant

Go for your firstprenatal visit as soon aspossible

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 bornPostpartum checkupbetween 21 and 56days after delivery

Childbirth EducationClassesDuring pregnancy, your body goesthrough various changes you may be

unaware of. Childbirth education classeswill help you understand these changesand help prepare you for delivery and

taking care of your baby after the delivery.HealthPlus Partners covers these classes

provided by qualified educators at most

hospitals or through certified MaternalInfant Health Programs. Please see yourdoctor for a referral.

Maternal Infant HealthProgram (MIHP)You may join the Maternal Infant HealthProgram (MIHP). This program has a healthcare team to help you have a healthy

pregnancy.

n It helps you learn about your newbaby.

n You must qualify for MIHP. Check with

your doctor if you would like to join.

The MIHP is covered by the State ofMichigan. You must use your mihealth

card for these services. Dont forget to goback 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.

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cant see, taste or smell lead. You may havelead in the dust, paint or soil in and around

your home or in your drinking water orfood. Because it does not break down

naturally, lead can remain a problem until

it is removed.

The long-term effects of lead in a childcan be severe. They include learning

disabilities, decreased growth, hyper-activity, impaired hearing and even braindamage. Many times there are no visible

signs of lead poisoning. If caught early,these effects 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 yourchild tested.

Immunizations (Shots)Having your child immunized is one ofthe most important ways you can protect

against serious diseases. Immunizations(or shots) are very safe. When you takeyour child for a checkup, be sure his or her

immunization record is checked and thatyou receive all recommended vaccines,

including a vaccine against pneumococcal

diseases. Be sure you get a copy of theimmunization record to take home withyou!

Colds and Sore ThroatsWhen your child is sick, you want to doeverything you can to help. Viruses cause

the common cold, most coughs and theflu. Antibiotics wont work on viral illnesses

to help your child feel better. Usingantibiotics for a cold or runny nose will notcure 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 sorethroat. Be sure to give your child all of the

medicine prescribed. Talk to your doctor tolearn more about the use of antibiotics.

Childrens Health Mens Health

Prostate CancerProstate cancer is now the most common

cancer among males. Men who are at thegreatest risk for developing it are those:

n Over age 45n Who have a history of prostate cance

in the family

n Who eat a diet high in fat

n Who are African American

Prostate cancer strikes black men moreoften than white men. Prostate cancer is

often slow-growing. In many cases, it canbe cured if it is treated before it spreads.

Prostate cancer may have no symptoms orsymptoms may include:

n Frequent urinationn Difficulty 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 yournext visit about which prostate screening

test is best for you. The prostate screening

with a Prostate Specific Antigen (PSA) testmay be appropriate for men age 50-65.

Childrens Health / Mens Health

Well Child VisitsKeep your child healthy! Make an

appointment for your child to get a wellchild visit, sometimes called EPSDT. At

this visit, the doctor will do a physical andgive any needed shots. He or she will also

do a vision and hearing screening andmake sure that your child is doing what

is expected for his or her age. Your doctoralso will make referrals for any neededfollow-up services.

A well child visit is important so the doctorcan see your child and talk to you about:

n Eyes, ears, height, weight and

lungs; check for normal growth anddevelopment

n Safety, injury and violence protectionn Risk for obesity, diabetes or heart

disease

n Lead poisoning (screening/testing atage 1 and again before age 2 years; if

not, it should be done between 3 to 6years)

n Shots

Babies and children should have well childvisits at the following ages:

n 2 to 4 days after birth

n 1 monthn 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, everyother 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 TestingMany things in our everyday lives put

infants, children and adults in danger oflead poisoning. About one in 22 children

in America have high levels of lead in theirblood, according to the Centers for DiseaseControl and Prevention.

You may have lead around your building

or home without knowing it because you

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Health and Wellness

Colorectal CancerColorectal cancer is the second leading

cause of cancer-related deaths Michiganfor men and women combined.. If

everyone age 50 to 75 years of age hadregular screening tests, at least one-third

of deaths from this cancer could beavoided. Everyone is at risk of developing

colorectal cancerall men, all women,all races. Screening for colorectal cancernot only detects the disease at ab early,

curable stage, but it can also prevent if byfinding and removing polys that might

become cancer. Please talk to your doctorabout 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 knowwhy

n A change in bowel habits, such ashaving stools that are narrower thanusual

n Losing weight and you dont knowwhy

If you have any of these symptoms, talk to

your doctor about being screened.

High Blood PressureHigh blood pressure is known as a silent

killer because it usually has no symptoms.Left unchecked, high blood pressure

can cause heart attacks, strokes, kidneydamage, eye damage and other serious

problems. High blood pressure can becontrolled. A blood pressure reading of120/80 puts you in the pre-hypertension

range. A measurement of 140/90 orhigher is considered high blood pressure.

Many things can raise blood pressure

temporarily so have blood pressurereadings at different times over a fewweeks or months. If the numbers are120/80 or above, make lifestyle changes to

lower your blood pressure. If the numbersare 140/90 or above, see your doctor and

follow his or her advice.

HealthQuestHealthPlus Partners has access to special

programs called HealthQuest Health andWellness. HealthQuest programs and

information can help you learn how to stayhealthy and live better. HealthQuest staff

work side by side with your doctors to giveyou accurate information about ways to

lower your risk of getting really sick.

HealthQuest has programs thatemphasize:

n The importance of prevention, earlydetection, screening and vaccinating

children

n The importance of regular visits tothe doctor for children, teenagers and

adultsn The importance of prenatal care and

good nutrition for mothers-to-be

n Womens health, includingmammograms, Pap smears and the

management of menopause

n Treatment for depression and mentalhealth concerns

n The importance of learning how to

live with asthma and diabetes

n The importance of controlling highblood pressure

n Ways to reduce cardiovascular

disease (strokes, heart attacks andhigh cholesterol)

n How to start an exercise program

n How to stop smoking

n How to eat healthy & better manageyour weight

For a list of programs and information,

please call the HealthQuest Departmenttoll-free at 1-800-345-9956, ext. 1943.

HealthQuest Online Healthand WellnessTo access our online wellness and healthinformation center, go to

www. healthplus.org and select the Health& Wellness button. This button will takeyou to all kinds of health information on

hundreds of health topics. Our healthencyclopedia has more than 1,800 health

topics. The online library has hundreds ofarticles and health facts to help you and

your family get and stay healthy. There are

also many online tools and quizzes youcan use to help you and your family get

and stay healthy.

Stop Smoking ProgramsHealthPlus Partners can help you endyour tobacco habit. Our programs andresources are designed to help you

consider the benefits of ending a smokinghabit. It will also offer help when you are

ready to quit. HealthPlus Partners offers avariety of tools and materials to help you

in the quitting process. The program helpssmokers (and former smokers) in a waythat 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 tocopays.

To enroll in any of the programs or torequest information call 1-800-345-9956,

ext. 1943, option 2, or email us [email protected].

Weight ManagementPrograms & Services

iCanChange Phone Coaching:Available to members whose weightputs them at risk for developing disease

and may already have chronic healthconditions such as high blood pressure

and/or diabetes. Members will have theadvantage of the iCanChange online

coaching as well as phone coaching

and an iCanChange kit that includes aworkbook, pedometer and measuring

tape. Members will be assigned to apersonal health coach who will motivate

and help them with weight managementfor one year!

Members can also choose from a variety of

Page 20 Mens Health / Health and Wellness

Mens Health


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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 bymeeting criteria defined by HealthPlus

Partners. To enroll, call 1-800-345-9956,ext. 1943, option 3 or email hquest@

healthplus.org.

HealthQuest Self-HelpInformation SupportKnowledge is power! HealthPlus can help

you learn more about a medical conditionor how to lead a healthier life. Our goal is

to make sure you have the facts to makegood health choices. You ask the question,

we will get the information to you onalmost ANY health topic. Here are sometopics that you can get from HealthPlus:

n Planning a Healthy Pregnancy

n Caring for your Newborn

n Cholesterol Control

n Eating and Exercising for BetterHealth

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-mailus at [email protected].

HealthQuest Toll FreeHealth Information LineMembers can access our HealthInformation 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 torequest any information they may need. To

access the line, members can call1-800-345-9956, ext. 1943 and select from

the following options and press option:

1. Information about childrens lead

testing2. Tobacco Cessation

3. Weight Management

4. Disease Management Programs

5. Mens or Womens Health

6. Pregnancy

7. HealthQuest Perks discountprograms

0. To leave a message

Community Resources

For your convenience, HealthQuestmaintains a list of health education classes

and resources offered in your community.Classes are listed by topic, county andprovider. Some programs and services

are free. Others charge a fee. Somecommunity 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 yourarea, call HealthQuest toll-free at

1-800-345-9956, ext. 1943 and chooseoption 0 to leave a message.

HealthQuest PerksProgramHealthPlus is continually looking for ways

to show members that we appreciate

them. In an effort to help you reach yourhealth goals, lower your risk of healthconcerns, and feel better about yourself,

the HealthQuest Perks Program is madeup of negotiated discounts for serviceswith companies that can provide health

& wellness related services for members.These companies include:

Weight Watchers: HealthPlus has joinedforces with Weight Watchers to bring

HealthPlus members special savings ratesand now off will reward its members

for participating! Simply complete 10weeks of your Weight Watchers plan and

HealthPlus will reimburse 50% of your cost(a maximum of $83)!

Jenny Craig:HealthPlus and Jenny Craighave teamed up to assist you. HealthQuestPerks now offers a Jenny Craig discount

just for being a valued HealthPlus member

Snap Fitness: HealthPlus memberscan enjoy free enrollment plus 10% off

monthly dues at Snap Fitness Centersnationwide.

Hurley Health & Fitness: Members cantake advantage of a $29 joining fee ($249

value) and half-off dues for the first threemonths. This offer cannot be combined

with any other offers.

EdgePark Medical Supplies:

HealthPlus has teamed up with EdgeParkMedical Supplies to offer free diabetic

meters and great discounts on variousmedical supplies such as scales, bloodpressure cuffs and other supplies not

covered under your medical benefit.Contact EdgePark for assistance.

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AsthmaAsthma 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 tothings like mold, pet dander, pollen, grass,

dust or weather changes. The swellingcan cause wheezing. It can also cause

shortness of breath or a cough whichdoes not go away, especially late at nightor early in the morning. Taking medicine

every day will help to prevent or decreasethe swelling. This makes breathing easier.

If you have asthma, there are ways you andyour doctor can work together to help you

live a normal, healthy life.

1. Measure your peak flow. Start bytaking a reading when you are nothaving symptoms. This is a time when

your doctor can work with you todevelop an asthma action plan. The

action plan will tell you what to doif your reading falls into one of threezones: red, yellow or green. Green

means that you are doing great usingyour daily routine. Yellow means to

be careful. You may need your rescueinhaler. Red means that you should

contact your doctor right away.

2. Keep a diary of your readings andsharing this with your doctor at each

visit

3. Adjust your medicine the way yourdoctor tells you to

4. Be aware of things that can bring on

an asthma attack

5. Always carry a rescue inhaler withyou

Asthma classes may be covered by

HealthPlus Partners. Call HealthQuest toll-

free at 1-800-345-9956, ext. 1943, option 4for details.

DiabetesDiabetes is a chronic illness. When youhave 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! Thecomplications of diabetes can be reducedor prevented if they are found early and

treated the right way.

The American Diabetes Association says

that everyone 45 and older should betested 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 orHispanic descent

n You are experiencing increased thirst,

increased urination or unexplainedweight 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 yourblood sugar (A1c) and lipids (LDL

bad cholesterol and HDL goodcholesterol)

n Urine tests to measure the protein

and albumin in your urine, to see howyour kidneys are functioning

n Monitoring of your blood pressure

n Foot examinations

Disease Management

Heart DiseaseHeart disease can happen when the bloodvessels that feed the heart get too narrow.

It can also be caused if the heart loses thepower to pump blood to the rest of the

body. This is called congestive heart failureBlocked 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 heartdisease. You are also more likely to getheart disease if you smoke or have high

blood pressure. High cholesterol makes itmore likely that you will get heart disease.

So does having a family history of peoplewith heart disease at an early age.

Some symptoms that could indicate heartproblems are:

n Swelling in your feet, legs orabdomen

n Shortness of breath that wakes youup at night

n A cough that gets worse or does not

go away

n Shortness of breath that gets betterwhen you sit up

Talk to your doctor if you have one or more

of these symptoms or risk factors. Youcan lower your chances of getting heartdisease if you eat right and exercise. Some

people may need to take medicine toimprove the flow of blood to their heart.

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Miscellaneous

New TechnologyWe 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 benefits of using thetechnology

n Deciding if it should be included as abenefit

If You Have Other InsuranceIf you have other insurance, please let us

know. This helps us to coordinate yourservices and make sure your bills are paid

timely. Call Customer Service at1-800-332-9161.

If You Receive a BillYou should never be asked to pay for anyauthorized, covered service. There are no

copays except for the copays describedin the benefits section of this handbook.

If you receive a bill for an authorized,covered service, please contact CustomerService.

If You Move or Lose

Medicaid EligibilityIf you move outside of the service area,you cannot be a HealthPlus Partners

member. You must notify the DHS office inyour new county.

If you lose your Medicaid eligibility withthe 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 different plan,

you must call Michigan ENROLLS at1-888-ENROLLS.

Request for DisenrollmentHealthPlus Partners may request your

disenrollment if:

1. You let someone else use your

HealthPlus Partners ID card forservices.

2. You cannot maintain a goodrelationship with your doctor.

Examples of a bad relationship are:

Refusing to follow the doctorsadvice

Continually going to an

emergency room for non-emergency care

Going to a provider who is notwith 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 thingshappen. 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 callingCustomer Service at 1-800-332-9161.

Fraud, Waste and AbuseHealthPlus Partners has a license to

do business as a health maintenanceorganization (HMO). Laws regulate

the health care services provided byHealthPlus Partners. HealthPlus Partners

members, employees and providers mustfollow these laws. HealthPlus Partners

must report all fraud waste or abuse.

Fraud can mean lying to get a benefit that

is not in your contract. Abuse can meandoing something that leads to extra costsfor 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 theconfidential Compliance Hotline at

1-888-706-1504. You also can write to:

Theresa M. Schurman, Esq.

Compl

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