Pro Care Health Plan, Inc.
MEDICAID
CERTIFICATE OF COVERAGE
Pro
Care Health Plan, Inc.
3956 Mount Elliott
Detroit, Michigan 48207
Pro Care Health Plan, Inc. is
a licensed health maintenance organization. Pro Care is a for-profit
corporation whose business office is at 3956 Mount Elliott Street, Detroit,
Michigan 48207. Pro Care is accredited by the Utilization Review Accreditation
Commission.
1.1
Certificate. This Certificate of Coverage is issued to
you because you are eligible for the Medicaid Program and you are enrolled in
Pro Care Health Plan (“Pro Care ”). If you are the head of the house and
others in your house are also enrolled in Pro Care this Certificate is issued
to you as the head of the house. In this Certificate you are called the
“Member”. Others in your house who are also enrolled in Pro Care are also
called the “Member”.
1.2
Rights and Responsibilities. This
Certificate describes and states the Member’s rights and responsibilities and Pro
Care’s rights and responsibilities. It is the Member’s responsibility to
read and understand this Certificate. By enrolling in Pro Care, the Member
agrees to comply with this Certificate.
1.3
Changes.
All changes to this Certificate must be in writing and signed by an authorized
officer of Pro Care. Verbal changes to this Certificate are not permitted even
if an employee of Pro Care tells the Member differently.
1.4
Assignment.
The Member’s rights to receive Covered Services under the Certificate are
personal to the Member. The Member may not give or sell these rights to any
other person. If the Member gives or sells, or tries to give or sell, his or
her rights to any other person, the Member’s enrollment in Pro Care may be
terminated under Article 9.
2.1
“Applicability” This part of the Certificate tells the meaning of
words that are used throughout this Certificate. If a word is defined in this
part of the Certificate, that word has the same meaning throughout this
Certificate.
2.3
“Certificate”
means this Certificate of Coverage between Pro Care and the Member, and all
changes and attachments to this Certificate.
2.4
“Communicable Diseases” means HIV/AIDS,
sexually transmitted diseases, tuberculosis and vaccine-preventable
communicable diseases.
2.5
“Contract Year” means a 12-month period ending on an
anniversary of the Member’s effective date of coverage.
2.6
“Copayment”
means the amount of money that the Member is required to pay directly to a
Participating or Non-Participating Provider for certain Covered Services.
2.7
“Covered Services” means the Medically Necessary services,
equipment and supplies set forth in Appendix A of this Certificate which
are covered health care benefits under this Certificate.
2.8
“Department” means the Michigan Department of Community
Health or its successor agency which is duly authorized to administer the
Medicaid Program in the State of Michigan.
2.9
“Emergency Medical Condition” means a medical
condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent lay person, with an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in (i) serious jeopardy to the health of
the individual or, in the case of a pregnant woman, the health of the woman or
her unborn child; (ii) serious impairment of bodily functions; or (iii) serious
dysfunction of any bodily organ or part.
2.10
“Emergency Services” means the
services which are Medically Necessary to treat an Emergency Medical Condition.
Emergency Services includes medical screening exams and stabilization
consistent with the federal Emergency Medical Treatment and Active Labor Act.
2.11
“Experimental” means a supply, drug, device, item,
procedure or treatment that meets one of more of the following standards:
A.
It cannot be lawfully marketed without the approval of the Food and Drug
Administration (FDA) and such approval has not been granted at the time of its
use or proposed use.
B.
It is the subject of a current investigational new drug or new device
application on file with the FDA.
C.
It is being provided pursuant to a Phase I or Phase II clinical trial.
D.
It is being provided pursuant to a written protocol which describes
among its objectives the determination of safety, efficacy or efficiency in
comparison of conventional alternatives.
E.
It is being delivered or should be delivered subject to the approval and
supervision of an Institutional Review Board as required and defined by federal
regulations, particularly those of the FDA or the Department of Health and
Human Services (HHS) or successor agencies, or of a human subjects or
comparable committee.
F.
The predominant opinion among experts as expressed in the published
authoritative literature is that usage should be substantially confined to
medical investigational or research settings.
G.
The predominant opinion among experts as expressed in the published
authoritative medical or scientific literature is that further experiment,
investigation or research is necessary in order to define safety, toxicity,
effectiveness or efficiency compared with conventional alternatives.
H.
At the time of its use or proposed use, it is not routinely or widely
employed or is otherwise not generally accepted by the medical community.
I.
It is not investigative in itself pursuant to any of the foregoing
criteria, and would not be Medically Necessary, but for the provision of a
drug, device, treatment, procedure or equipments which meets any of the
foregoing criteria.
J.
It is deemed experimental, investigational or research under Pro Care’s
insurance or reinsurance agreements.
An antineoplastic drug which is a
covered benefit in accordance with Section 3406e of the Insurance Code is not
an Experimental drug.
2.12
“Family Planning Services” are any
medically approved diagnostic evaluation, drugs, supplies, devices, and related
counseling for the purpose of voluntarily preventing or delaying pregnancy or
for the detection or treatment of sexually transmitted diseases.
2.13
“Health Professional” means an
individual licensed, certified or authorized in accordance with Michigan law to
practice a health profession in Michigan.
2.14
“Hospital”
means a facility licensed as a hospital under Michigan law, except for a
facility licensed or operated by the State of Michigan as a mental health or
psychiatric hospital.
2.15
“Hospital Services” mean those Covered Services which are
provided by a Hospital.
2.16
“Insurance Code” means the Michigan Insurance Code of 1956,
as amended, MCL 500.101 et seq.
2.17
“Medicaid Contract” is the contract between the Department and
Pro Care under which Pro Care agrees to arrange for Covered Services for
Members.
2.18
“Medicaid Program” means the medical assistance program
established by Michigan and federal law to provide comprehensive health care
services for eligible individuals.
2.19
“Medical Director” means a Physician designated by Pro Care
to supervise and manage the quality of care aspects of Pro Care’s programs and
services.
2.20
“Medically Necessary” means the
services, equipment or supplies necessary for the diagnosis, care or treatment
of the Member’s physical or mental condition as determined by the Medical
Director in accordance with accepted medical practices and standards of care at
the time of treatment. Medically Necessary does not in any event include any
of the following:
A.
services rendered by a Health Professional that do not require the
technical skills of the Health Professional; or
B.
services, equipment or supplies furnished mainly for the personal
comfort or convenience of the Member, any individual who cares for the Member,
or any individual who is part of the Member’s family; or
C.
that part of the cost of service, equipment or supply which exceeds that
of any other service, equipment or supply that would have been sufficient to
safely and adequately diagnose or treat the Member’s physical or mental
condition, except when rendered by, or provided upon the referral of, a PCP, or
otherwise authorized by Pro Care, in accordance with Pro Care ’s procedures.
2.21
“Medicare”
means the health benefits program primarily for elderly and disabled
individuals established under Title XVIII of the federal Social Security Act,
42 U.S.C. 1395 et seq.
2.22
“Member”
means a Medicaid Program beneficiary enrolled in ProCare and on whose behalf
the Department has paid a Premium in accordance with the Medicaid Contract.
2.23
“Non-Covered Service” means a health
care service which is not a covered health care benefit under this Certificate.
2.24
“Non-Participating Provider” means a Health
Professional, a Hospital, pharmacy, laboratory, or any other health care
provider or supplier who does not have a contract with ProCare to render
Covered Services to Members.
2.25
“Office of Insurance” means the
Michigan Office of Financial and Insurance Services, or its successor agency,
which is duly authorized to regulate health maintenance organizations in
Michigan.
2.26
“Participating Hospital” means a Hospital,
which has a contract with ProCare to provide Covered Services to Members.
2.27
“Participating Physician” means a
Physician who has a contract with ProCare to provide Covered Services to
Members.
2.28
“Participating Provider” means a
Participating Physician, Participating Hospital, or any other Health
Professional or health care provider or supplier which has a contract with ProCare
to render Covered Services to Members.
2.29
“PCP”
means the Participating Provider who is responsible for providing primary care
Covered Services for the Member and arranging and coordinating all aspects of
the Member’s health care.
2.30
“Physician”
means a doctor of allopathic or osteopathic medicine licensed to practice
medicine in the State of Michigan.
2.31
“Pro Care ”
means Pro Care Health Plan, Inc. a Michigan for profit corporation licensed by
the State of Michigan as a health maintenance organization.
2.32
“Premium”
means the amount of money paid by the State of Michigan to Pro Care to secure
Covered Services for Members under the Medicaid Contract.
2.33
“Service Area” means the geographic area in which Pro Care
is authorized by the Office of Insurance and Department to operate as a health
maintenance organization and Medicaid health plan.
2.34
“Specialist” means a Participating Physician, other
than a PCP, who provides Covered Services to Members upon referral by the PCP
and, if required, prior authorization by Pro Care.
2.35
“Urgent Care” means the treatment of a medical condition
that requires prompt medical attention but is not an Emergency Medical Condition.
3.1
Eligibility. The Department has sole authority to
determine the eligibility of individuals or families for the Medicaid Program.
Pro Care does not have any authority to determine whether an individual is
eligible for the Medicaid Program.
3.2
Enrollment.
An individual may enroll in Pro Care only if the individual is eligible for the
Medicaid Program and lives within the Service Area. The Department or its
Enrollment Services Contractor has sole authority for enrolling individuals in Pro
Care . An eligible individual may choose Pro Care, or the Department may choose
Pro Care for the eligible individual. Pro Care will not deny enrollment to,
expel, or refuse to re-enroll any individual because of the individual’s health
status or need for services.
3.3
Effective Date of Coverage. The effective date of
the Member’s coverage by Pro Care is the first day of the month after the
Department notifies Pro Care in writing of the enrollment. However, if the
Member is in any inpatient setting on this date, Pro Care is not responsible
for arranging or paying for any health care services for the Member, including
the inpatient stay and any charges connected with that stay. Pro Care is
responsible only for arranging and paying for Covered Services after the date
of the Member’s discharge from the inpatient setting. Pro Care is not
responsible for arranging or paying for any health care services for an
individual before the effective date of coverage in Pro Care, except for
newborns as set forth below. Pro Care is not responsible for arranging or
paying for any health care services for an individual during a period of
retroactive eligibility (as determined by the Department), except for newborns
as set forth below. Pro Care or the Department will notify the Member of the
effective date of enrollment in ProCare and coverage under this Certificate.
3.4
Newborns.
The Member’s newborn child is eligible for the Medicaid Program for the month
of birth, and may be eligible for up to one-year longer as determined by the Department.
The newborn child is automatically enrolled in Pro Care if the child’s mother
is eligible for the Medicaid Program and is enrolled in Pro Care at the time of
the child’s birth. The newborn is entitled to Covered Services retroactive to
the date of birth. The Member must notify the Member’s Michigan Department of
Human Services caseworker as soon as possible after the birth of a newborn. The
Department has sole authority to determine the continued eligibility and
enrollment of a newborn.
3.5
Change of Residence. The Member
must notify Pro Care when the Member moves to a residence outside of the
Service Area. If the Member moves outside of the Service Area, the Member’s
enrollment in Pro Care may be terminated under Article 9. However, the
Member is entitled to Covered Services until the Member is disenrolled from Pro
Care. The Member must notify Pro Care either by telephoning or writing
to the Member Services Department. Pro Care will notify the Department of changes
in accordance with Department procedures.
3.6
Change in Family Size. The Member must notify
Pro Care as soon as possible of changes in the Member’s family such as a
divorce, an adoption or change in child custody. The Member must notify Pro Care
either by telephoning or writing to the Member Services Department. Pro Care
will notify the Department of changes in accordance with Department procedures.
3.7
Final Determination. In all cases, the
Department will make the final determination of an individual’s eligibility for
the Medicaid Program and the individual’s enrollment and right to continue
enrollment in Pro Care.
4.2
Medical Questionnaires and Other Forms. The Member
must complete and submit medical questionnaires and other forms that are
reasonably requested by Pro Care. The Member must provide true, correct and
complete information on these questionnaires and forms. If the Member
intentionally provides false or misleading information or omits a material fact
on a questionnaire or form, the Member’s enrollment in Pro Care may be
terminated under Article 9 of this Certificate.
4.3
Identification Card. Pro Care will
issue an Identification Card to the Member. The Member must present the
Identification Card to Participating Providers each time the Member obtains
Covered Services. The Identification Card is the property of Pro Care and Pro Care
may request the Member to return an Identification Card at any time.
4.4
Misuse of Identification Card. If the Member
misuses the Identification Card, permits another person to use the Card, or
otherwise defrauds (or tries to defraud) Pro Care, Pro Care may immediately
request the Member to return the Identification Card to Pro Care. The Member’s
enrollment in Pro Care, and the enrollment of any other Members in the
household, may be terminated under Article 9 if the Member misuses the Card, permits
another person to use the Card, or otherwise defrauds or tries to defraud Pro Care,
4.5
Loss or Theft of Identification Card. The Member
must promptly notify Pro Care of the loss or theft of the Member’s
Identification Card. The Member must notify Pro Care either by telephoning or
writing to the Member Services Department.
4.6
Member Handbook. The Member will receive a copy of the
Member Handbook when the Member enrolls in Pro Care. Pro Care will notify the
Member of any changes to the Member Handbook. The Member may request
additional copies of the Member Handbook at any time by telephoning or writing
to the Member Services Department.
4.7
Grievance and Appeal Procedures. Pro Care has
internal procedures for receiving, processing and resolving Member concerns
relating to any aspect of health services or administrative services, including
authorizations for medical services. An external grievance and appeal procedure
administered by the Office of Insurance and a Medicaid Fair Hearing Process are
also available to Members. The Member Handbook describes Pro Care’s internal
grievance and appeal procedure, the Office of Insurance external grievance
procedure, and the Medicaid Fair Hearing Process. The Member may call Pro Care’s
Member Services Department if the Member has a question concerning Pro Care’s
internal grievance procedures or the external processes. The telephone number
of the Member Services Department is in the Member Handbook.
4.8
Fraud and Abuse. Pro Care has a compliance program for
identifying, addressing and reporting instances of fraud and abuse. The Member
should report to Pro Care any suspected fraud or abuse involving the Medicaid
Program. The Member Handbook has information about reporting suspected fraud
and abuse to Pro Care or government agencies. Abuse includes health care
provider or Member practices that result in unnecessary costs to the Medicaid
Program or in reimbursement for services that are not medically necessary. Fraud
is an intentional deception or misrepresentation made by a person with the
knowledge that the deception or misrepresentation could result in some
unauthorized benefit to the person or some other person, including any act
constituting fraud under federal or state law.
4.9
Reasonable Accomodation. Pro Care will make reasonable
accommodation for Members with hearing and/or visual impairments.
4.12
Member Health and Other Information. Pro Care must
keep the Member’s protected health information confidential under Michigan and
federal laws, including HIPAA. Pro Care must not use or disclose the Member’s
protected health information to other persons if the use or disclosure violates
state or federal laws. Pro Care will provide the Member a Notice of Privacy
Practices that describes the Member’s rights and obligations and Pro Care’s
rights and obligations regarding the Member’s protected health information.
The Department and the federal Centers for Medicare and Medicaid Services will
have access to Members’ medical records without obtaining Members written
approval before requesting the medical records. Pro Care must comply with
state and federal law regarding the Member’s right to access and review the
Member’s medical record. Pro Care will protect from unauthorized disclosure all
Member information collected, maintained or used in the administration of the
Medicaid Contract.
4.13
Pro Care’s Board of Directors. As required by
law, at least one-third of the Directors on Pro Care’s Board of Directors must
be adult Members elected by subscribers. Pro Care will notify all subscribers
of the date of subscriber elections and each subscriber will have the right to
vote for Member nominees for the Board of Directors. Nominations and elections
of Directors will be reported in Pro Care’s periodic newsletter. The Member
may contact Pro Care’s Member Services Department for information on becoming a
Director.
4.14
Protection Against Liability for Payment and Balance Billing. The
Member will not be liable for payment to Pro Care or health care providers for
Covered Services provided to the Member, except as specifically stated in this
Certificate.
4.15
Pro Care’s Policies and Procedures. The Member is
responsible for becoming familiar with and following the policies and
procedures which Pro Care adopts from time to time to administer the Medicaid
Contract, the Certificate and Pro Care . Pro Care will provide copies of its
policies and procedures to the Member upon request, and will provide
information regarding policies and procedures in Pro Care ’s newsletter and
other written communication to Members.
4.16
Member Request for Information. The Member should refer to Pro
Care’s Provider Directory for a listing of current Participating Providers,
including names and locations of Participating Providers by specialty or type and
which Participating Providers will not accept new Members. This Certificate
and the Member Handbook describe limitations of accessibility and referrals to
specialists, prior authorization requirements and Non-Covered Services. In
addition, as required by the Insurance Code, upon request of the Member, Pro Care
will provide a description of any of the following information requested by the
Member:
A.
Professional credentials of Participating Physicians and other health
professionals who are Participating Providers;
B.
The licensing verification telephone number for the Michigan Department
of Community Health that can be accessed for information regarding disciplinary
actions or open complaints against a health professional Participating
Provider;
C.
The financial relationship between Pro Care and any Participating
Provider; or
D.
A telephone number and address to obtain additional information
concerning the Provider Directory, limitations of accessibility and referrals
to specialists, prior authorization requirements, Non-Covered Services or any
of the items described above in paragraphs A through C.
5.1
Choosing a PCP. At the time of
enrollment in Pro Care, the Member should choose his/her PCP from Pro Care’s
Provider Directory. The Provider Directory lists all Participating Physicians
who are primary care Physicians. The Member may choose a clinic as a PCP if
the clinic is listed in the Provider Directory as a PCP. If a Member is a
minor or otherwise incapable of selecting a PCP, an authorized person may
select a PCP on behalf of the Member. An authorized person may select a
pediatrician who is a Participating Physician as the PCP for a Member who is a
minor. Pro Care will allow a Specialist to be the Member’s PCP if it is
necessary for the Specialist to manage the Member’s medical condition. This
might be necessary for a medical condition such as diabetes, end-stage renal
disease, HIV/AIDS or other chronic disease or disability. If Pro Care cannot
honor the Member’s choice of a PCP, Pro Care will notify the Member to allow
the Member to choose an alternate PCP or to disenroll. Disenrollment will be
determined by the Department. Pro Care will select a PCP for a Member if the
Member (or an authorized person on behalf of the Member) does not select a PCP within
ten days of the effective date of enrollment. Pro Care will notify the Member
of the PCP that Pro Care selected for the Member. Pro Care will inform the
Member of the hours of operation and office locations of the PCP that the
Member has chosen or that Pro Care has selected for the Member.
5.2
Changing a PCP. The Member may change to a different PCP
by making a verbal or written request to Pro Care ’s Members Services Department.
A PCP change is effective on the first day of the following month if requested
by the 25th day of the current month. The member should verify the
effective date of change when the Member requests the change.
5.3
Role of PCP. The Member’s PCP provides primary care
services and arranges and coordinates the provision of other health care
services for the Member, including referrals to specialists, ordering lab tests
and x-rays, prescribing medicines, and arranging hospitalization.
5.4
Specialists and other Participating Providers. Except as
otherwise expressly stated in this Certificate, the Member must obtain a
referral from the PCP or, when required, authorization from Pro Care, before
the Member receives Covered Services from a Specialist or other Participating
Provider. If the Member does not obtain the necessary referral or
authorization from the PCP or Pro Care, Pro Care will not pay for any of the
medical services, equipment, and supplies that the Member receives from the
Specialist or other Participating Provider. It is not necessary to obtain a
referral or authorization to receive the following services from Participating
Providers: (i) Emergency Services; (ii) Family Planning Services; (iii)
outpatient mental health services for up to 20 visits per Contract Year; (iv)
covered vision services; or (v) an annual well-woman examination and routine
obstetrical and routine gynecological services from an obstetrician-gynecologist.
5.5
Non-Participating Providers. The Member may
occasionally require Covered Services from Non-Participating Providers. On
these rare occasions, the Member must obtain authorization from Pro Care before
the Member receives any Covered Services from the Non-Participating Provider,
except as otherwise specifically stated in this Certificate. If the Member
does not receive authorization from Pro Care, Pro Care will not pay or
reimburse the Non-Participating Provider or the Member for any of the medical
services, equipment and supplies received from the Non-Participating Provider,
except under the following circumstances: (i) the services are Medically
Necessary Covered Services; and (ii) the services could not reasonably
be obtained from a Participating Provider; and (iii) Pro Care did not
respond to a the request for authorization within 24-hours after the request
was made. If Pro Care does not have a Participating Provider available for a
second opinion within its provider network, the Member may obtain a second
opinion from a Non-Participating Provider at no cost to the Member with Pro Care’s
prior authorization. It is not necessary to obtain authorization from Pro Care
before receiving the following services from Non-Participating Providers: (i) Emergency
Services; (ii) treatment of Communicable Diseases at the Member’s local health
department; (iii) Family Planning Services; and (iv) Covered Services from a
CAHCP provider. If there is not a Participating Provider Federally Qualified
Health Center in the county where the Member resides, the Member may obtain routine
health care services from a Non-Participating Federally Qualified
Health Care Center without prior authorization from Pro Care.
5.6
Independent Contractors. Pro Care contracts
with Participating Providers who provide Covered Services to Members. The
Participating Providers are independent contractors. They are not employees,
agents, partners or co-venturers of Pro Care. Participating Providers are
solely responsible for exercising independent medical judgments. A
Participating Provider and the Member may initiate or continue medical services
despite Pro Care ’s decision that the services are Non-Covered Services. Pro Care
will not pay or reimburse the Participating Provider or the Member for any of
these Non-Covered Services. The Member may appeal Pro Care ’s decision on
whether services are Covered Services by following the grievance and appeal procedures
described in the Member Handbook.
5.7
Availability of Participating Providers. Pro Care does
not represent or promise that a specific PCP or other Participating Provider
will be available to render services throughout the period that the Member is
enrolled in Pro Care. Pro Care or the Participating Provider may terminate the
provider contract or limit the number of Members that the Participating
Provider will accept as patients. If the Participating Provider contract of
the Member’s PCP is terminated, the Member must select another PCP. Pro Care
will notify the Member of the termination of the PCP’s Participating Provider
contract and will assist the Member in choosing a new PCP before termination of
the contract. If a Specialist who is rendering services to a Member ceases to
be a Participating Provider, the Member must cooperate with the Member’s PCP or
Pro Care in referring the Member to another Specialist to render the Covered
Services.
5.8
Inability to Establish or Maintain a Physician-Patient Relationship. If the Member
is unable to establish or maintain a satisfactory relationship with a PCP or a
Specialist, Pro Care may request the Member to select another PCP, or may
arrange to have the Member’s PCP refer the Member to another Specialist. If
the Member is unable to establish or maintain a satisfactory relationship with
Participating Physicians, the Member’s enrollment in Pro Care may be terminated
under Article 9.
5.9
Refusal to Accept or Follow Treatment. For personal
or religious reasons, a Member may refuse to accept or follow the treatment(s)
or procedure(s) recommended as necessary by a Participating Physician. The
Participating Physician may request that the Member select another
Participating Physician if a satisfactory relationship with the Member cannot
be maintained because of the Member’s refusal to follow such treatment
recommendations or orders.
6.2
Copayments.
A Member must pay or arrange for payment of Copayments at the time a Covered
Service is provided. Copayments, if any, are set forth in Appendix D of
the Certificate. A Participating or Non-Participating Provider may require the
Member to pay the Copayment in cash at the time of delivery of the Covered
Services. A Participating or Non-Participating Provider may not deny Covered
Services to the Member due to the Member’s inability to pay the Copayment.
6.3.4
If the Member requests reimbursement for Covered Services, the Member
must submit acceptable proof that the Member paid the Non-Participating
Provider for the Covered Services. The Member should submit the proof of
payment at the same time as the request for reimbursement. If the Member is
not reasonably able to submit proof of payment at the same time the Member
makes a request for reimbursement, Pro Care will reimburse the Member for the
Covered Services if the Member provides proof of payment as soon as reasonably
possible. However, ProCare will not be obligated to reimburse the Member if
the Member submits proof of payment more than 12 months after the date Covered
Services were provided to the Member.
6.4
Non-Participating Providers. Pro Care will
not pay a Non-Participating Provider or reimburse the Member for any services,
supplies or equipment provided by a Non-Participating Provider that are not
authorized in advance by Pro Care except under the following circumstances:
(i) the services are Medically Necessary Covered Services; and (ii) the
services could not reasonably be obtained from a Participating Provider; and
(iii) Pro Care did not respond to a the request for authorization within
24-hours after the request was made. Pro Care will pay Non-Participating
Providers for Emergency Services, Family Planning Services, treatment of
Communicable Diseases at the Member’s local health department and Covered
Services by a CAHCP provider as set forth in this Certificate.
6.5
Non-Covered Services. Pro Care will
not pay a Participating Provider or a Non-Participating Provider, or reimburse
the Member, for any Non-Covered Services received by the Member if the Member
knew or reasonably should have known that the services were Non-Covered
Services at the time the services were rendered. Pro Care may recover from the
Member the expenses for Non-Covered Services.
7.1
Covered Services. The Member is entitled to the Covered
Services specified in Appendix A when all of the following conditions are
met:
7.2
Emergency Services. In case of an Emergency Medical Condition,
the Member should go directly to a Hospital emergency room. The Member, the
Hospital or a responsible person must notify Pro Care as soon as possible after
the Member receives Emergency Services. All follow-up and continuing care that
are not Emergency Services must be authorized in advance by Pro Care or the
Member’s PCP. Pro Care will not deny payment for Emergency Services up to the
point of stabilization because of the final diagnosis or lack of prior
authorization.
7.3
Urgent Care. Urgent Care must be authorized in advance
by the Member’s PCP. All follow-up and continuing care must be authorized in
advance by the Member’s PCP.
7.5
Out-of-Area Services.
7.5.1
Covered Services. Emergency Services are covered by Pro Care
while the Member is temporarily out of the Service Area. The Member, the
Hospital or a responsible person must notify Pro Care as soon as possible after
the Member receives Emergency Services. Urgent Care and other Covered Services
must be authorized in advance by Pro Care. If the Covered Services are Medically
Necessary and could not be reasonably obtained from a Participating Provider,
the Covered Services are considered authorized by Pro Care if Pro Care does not
respond to a request for authorization within 24 hours of the request.
7.5.2
Hospitalization. If an Emergency Medical Condition requires
hospitalization, the Member, the Hospital or a responsible person must notify Pro
Care as soon as possible after the emergency hospitalization begins. Pro Care
may require the Member to move to a Participating Hospital when it is
physically possible to do so.
7.6
Coordination of Care Services. Pro Care will
refer Members to agencies or others for certain services, such as certain
behavioral health and developmental disability service, which the Member may
be eligible to receive, but which are not Covered Services under this
Certificate. These services are set forth on Appendix B. The State of
Michigan or other agency or entity will be responsible for paying for these
services.
8.1
Exclusions.
The services, equipment and supplies listed on Appendix C are
Non-Covered Services. In addition, any health care services provided before
the effective date of coverage or after the coverage under this Certificate has
terminated are Non-Covered Services, except as otherwise expressly stated in
this Certificate.
9.1
Term.
This Certificate takes effect on the effective date of coverage as specified in
Article 3. This Certificate continues in effect from year to year thereafter
unless otherwise specified in the Medicaid Contract or unless terminated in
accordance with this Certificate.
9.3.1
The Department may disenroll the Member when any of the following occurs:
A.
the Department erroneously enrolled the individual in Pro Care; or
B.
the Member ceases to be eligible for the Medicaid Program as determined
by the Department; or
C.
the Member dies; or
D.
the Member moves out of the Service Area.
9.3.2
In all cases, the Department will make the final decision concerning
disenrollment of the Member under this Section 9.3. The effective date of
disenrollment will be determined by the Department.
9.3.3
The Member’s coverage under this Certificate terminates automatically on
the effective date of the Member’s disenrollment, except as provided in Section
9.6.
9.4.1
Pro Care may request the Department to disenroll the Member for any of
the following reasons:
A.
the Member becomes medically eligible for the Children’s Special Health
Care Services program and the family chooses to enroll in the CSHCS program; or
B.
the Member is admitted to a nursing facility for custodial care or
remains in a nursing facility for rehabilitative care for longer than 45 days;
or long-term care facility unless the Member is a hospice patient; or
C.
the Member is admitted to a State of Michigan psychiatric hospital or an
intermediate care facility for the mentally retarded as defined by the Medicaid
Contract; or.
D.
the Member is incarcerated in a correctional facility; or
E.
the Member is served under the Home & Community Based Elderly
Waiver; or
F.
the Member is unable to establish or maintain, after reasonable attempts
by two Participating Physicians, a satisfactory physician-patient relationship;
or
G.
the Member makes material lies, omits facts, or otherwise commits fraud
in completing medical questionnaires or other forms requested by ProCare or
the Department; or
H.
the Member’s circumstances change such that the Member no longer meets
the criteria for enrollment in ProCare as defined by the Department;
I.
the theft or alteration of prescriptions, the misuse or fraud in the use
of the Member’s Identification Card, or other fraud or misrepresentation in the
Member’s use of ProCare ’s benefits and services; or
J.
the Member’s physical or verbal conduct is violent, threatening, abusive
or obstructive to ProCare’s personnel, Participating Providers or other Members;
or
K.
the Member is non-compliant with or misuses Pro Care ’s benefits and
services, including failure to follow treatment plan, unauthorized repeated use
of Non-Participating Providers, repeated use of Hospital emergency rooms for
conditions that are not Emergency Medical Conditions, and other non-compliant situations
that impede care; or
L.
the Member fails to cooperate in coordinating benefits or subrogating
the Member’s rights of recovery.
9.4.4
The Member’s coverage under this Certificate terminates automatically on
the effective date of the Member’s disenrollment, except as provided in Section
9.6.
9.5.1
The Member will remain enrolled in ProCare for 12 months after the
effective date of enrollment, except as follows:
A.
If the Member has changed enrollment from another Medicaid health plan
to ProCare, the Member may request the Department to disenroll the Member
without cause from Pro Care at any time during the first 90 days after the
effective date of enrollment in Pro Care; or
B.
The Member may disenroll from Pro Care during an annual open enrollment
period as determined by the Department. The Department will notify the Member
of the annual open enrollment period; or
C.
At any time, the Member may request the Department to disenroll the
Member from Pro Care because of poor quality of care, lack of access to providers
or necessary specialty Covered Services, or other good reason as determined by
the Department.
9.5.2
After enrollment in Pro Care for 12 months, the Member may request the
Department to disenroll the Member from Pro Care as follows:
A.
The Member may disenroll from Pro Care during an annual open enrollment
period as determined by the Department. The Department will notify the Member
of the annual open enrollment periods; or
B.
At any time, the Member may request the Department to disenroll the
Member from Pro Care because of poor quality of care, lack of access to providers
or necessary specialty Covered Services, or other good reason as determined by
the Department.
9.6
Continuation of Benefits. If the Member
is an inpatient at a Hospital on the date that the Member’s enrollment in Pro Care
terminates, Pro Care is responsible for payment for the inpatient Hospital
stay until the date of discharge, subject to exceptions for disenrollments
based on Children’s Special Health Care Services enrollments.
10.1
Purpose.
In order to avoid duplication of benefits to Members by Pro Care and other
Payers, Pro Care will coordinate benefits for the Member under this Certificate
with benefits available from other Payers that also provide coverage for the
Member.
10.2
Notification. The Department will furnish Pro Care with
notice of all other Payers providing health care benefits to the Member. The
Member must notify Pro Care of any health insurance or health plan benefits,
rights to payment and money paid for any claims for health care when the Member
learns of them. The Member must also notify Pro Care when payment of health
care benefits from any other Payer becomes available to the Member.
10.3
Order of Benefits. In establishing the order of Payer
responsibility for health care benefits, Pro Care will follow coordination of
benefits guidelines authorized by the Department and Office of Insurance and
applicable provisions of the Michigan Coordination of Benefits Act, Public Act
64 of 1984, as amended, MCL 550.251 et seq. For Members
with Medicare coverage, Medicare will be the primary payer ahead of Pro Care.
A.
determine whether and to what extent the Member has health insurance or
other health benefit coverage for Covered Services; and
B.
establish, in accordance with this Article, priorities for determining
primary responsibility among the Payers obligated to provide health care
services or health insurance; and
C.
require the Member, a Participating Provider or a Non-Participating
Provider to file a claim with the primary Payer before it determines the amount
of ProCare ’s payment obligation, if any; and
D.
recover from the Member, Participating Provider or Non-Participating
Provider, as applicable, the expense of Covered Services rendered to the Member
to the extent that such Covered Services are covered or indemnified by any
other Payer.
10.5
Construction. Nothing in this Article shall be
construed to require ProCare to make a payment until it determines whether it
is the primary Payer or the secondary Payer and the benefits that are payable
by the primary Payer, if any.
10.6
Definition.
As used in this Article 10, “Payer” means all insurance and other benefit plans,
policies, and programs that may be liable for payment or reimbursement for
health care services rendered to the Member, including Medicare, employer-sponsored
health plans, self-funded and self-insured plans, commercial health insurance
carriers, automobile insurance and workers compensation and other private and
governmental plans, policies and programs.
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