WELCOME LETTER
Dear New
Member:
We
look forward to giving you the highest quality of care and service available.
Please read
the Member Handbook. It provides information about:
•
Who we are
•
How to contact us and
•
The Services and
Benefits we provide.
On the
inside front and back covers, we have a Quick Reference. It should help to
answer basic questions.
The first
step toward managing your health care is selecting a Primary Care Physician
(PCP). PCP’s are doctors in the following areas:
•
Family or General
Practice,
•
Internal Medicine,
Pediatrics, and/or
•
Obstetrics/Gynecology
If you
haven’t selected a PCP through Michigan ENROLLS, then please call us at
313-267-0300 (local) or 1-877-255-3055 (toll free) and we will help you.
If you want
a Provider Directory or Certificate of Coverage, we can mail them to you or you
can look at them on our website (www.procarehp.com). If you have any
questions, please call us at 313-267-0300 (local) or 1-877-255-3055 (toll
free).
Sincerely,
Member
Services
WELCOME TO PRO CARE HEALTH PLAN,
INC. (PRO CARE)
This
handbook explains our services and benefits. Please:
•
Keep this handbook and
refer to it whenever you have a question
•
Share this handbook
with everyone in your household that is enrolled with us
If
you need another copy of this handbook, the Certificate of Coverage, or the
Provider Directory call us at 1-313-267-0300 (local) or 1-877-255-3055 (toll
free). Telephones are answered 24 hours a day either by the Member Services or
a Call Center. If you are hearing impaired call the toll free Michigan Relay
number at 1-800-649-3777.
We
are here to give you information when you need it. We can help you for reasons
such as:
o
To change your
address
o
To change your
doctor
o
With
transportation
o
With your
questions and concerns
o
If you get a
bill
We
are a licensed health maintenance organization (HMO) that is contracted with
the State of Michigan to provide a complete range of health care services for
our members. Covered Services are listed in this member handbook and in the
Pro Care Medicaid Certificate of Coverage. Many of the covered services are
available to you only when they are provided or authorized by your doctor.
Please read this book and keep it in a safe place for future use. If you have
any questions about Pro Care, the member handbook or your health care coverage
contact Member Services.
Member
Services can help with your questions. Our specialists know all about Pro Care
Health Plan.
•
Member Services
specialists are available from 9:00 a.m. to 5:00 p.m. Monday through Friday at 1-313-267-0300
(local) or 1-877-255-3055 (toll free)
•
For help 24 hours a
day, 7 days a week, call us at 1-313-267-0300
(local) or 1-877-255-3055 (toll free) and our Call Center will help you
•
Visit our business
office during normal business hours (Monday-Friday 9 am-5 pm) We are located at:
Pro Care Health Plan
3956 Mt. Elliott
Detroit, MI 48207
•
Always have your Pro
Care Member ID card and your mihealth card ready when you call.
HOW
TO USE PRO CARE HEALTH PLAN
How
Do I Choose My Primary Care Provider (PCP)
Your
Primary Care Provider (PCP) is the doctor that will take care of your medical
needs. Your PCP will provide or arrange for any covered medical services that
you need.
As a member
of Pro Care you have the right to choose your Primary Care Provider (PCP). Be
sure to choose a PCP close to your home. You can use the Provider Directory to
help you do this.
Once you
choose your PCP call us at 1-313-267-0300 (local) or 1-877-255-3055 (toll free)
and tell us your choice. We can help you choose a PCP if you need help. If
you do not choose a PCP, we will choose one for you.
Women need to select a PCP, but may see an
OB/GYN for annual well-woman examinations and routine OB/GYN care without a
referral from their PCP. Children also need to select a PCP and may choose to have
a Pediatrician, but they may also see a Pediatrician without referral from Pro
Care. Members can also get services from a Child and Adolescent Health Center provider without a referral from their PCP or Pro Care.
When you have chosen your PCP, call
and schedule an appointment for a medical checkup or to be seen for a
non-emergency illness. It is a good idea to meet with your PCP before you
get sick so you can talk about your medical past. When you go to your
PCP’s office for the appointment, always take your mihealth card and your Pro
Care Member ID card. There is important information about your Medicaid
eligibility and coverage on the cards.
Can A Specialist Be My PCP?
Persons with a chronic health condition may
need to see a specialist to get needed care. In limited cases, it may be
better for the specialist to be responsible for all of your health care needs.
Examples of chronic problems with your health include: diabetes, kidney
disease, HIV/AIDS, or other chronic diseases or disabilities. Call us if you
think you need a specialist to be your PCP.
Can I Use a Federally Qualified Health Center (FQHC)?
You may choose to receive medically
necessary health care services from a Federally Qualified Health Center
(FQHC). You need to know that:
•
You
do not need a referral from your PCP
•
The
FQHC needs to get a referral from us before referring you to another provider
•
You
can call us at 1-313-267-0300 (local) or 1-877-255-3055 (toll free) to get more
information about FQHCs
How
Do I Request a PCP Change?
If you want to change your current PCP call us at -313-267-0300
(local) or 1-877-255-3055 (toll free). Remember:
•
Your
assignment to a new PCP will be effective on the first day of the following
month if requested by the 25th of the current month
•
You
should verify the effective date of change with us when you request the change
•
While
the change is being made, you should continue to see your current PCP
•
Anytime
you change your PCP, Pro Care will send you written notification with your new
PCP’s name.
When Do I Call My PCP?
Call your PCP when you need:
•
A
check-up
•
Non-emergency
medical care
•
Preventive
care
•
Well
baby-well child
•
Diagnostic
tests, lab work, x-rays
•
To
see a specialist or get a referral
•
To
be admitted to a hospital
How Do I Make An Appointment With My PCP?
When you need an appointment, you should:
•
Call
your PCP’s office during regular business hours to set up an appointment
•
Tell
them that you are a Pro Care member
•
Tell
them why you need to see the doctor
•
Call
your doctor early in the morning for an appointment for that day
•
Leave
a message if you reach their answering machine
We
are available by phone 24 hours a day for questions about care after normal
hours. Ask your PCP for his/her after hour’s number as well.
What Should I Do Before My Appointment?
You should always be:
•
On
time for your appointment
•
Prepared
for your appointment
o
Have
your questions ready
o
Have
your information about your problem and medications
•
Sure
to take your mihealth card and your Pro Care Member ID card
What Do I Need To Do To Change Or Cancel An Appointment?
If you cannot keep your appointment, you should:
•
Call
to cancel at least 24 hours before the appointment. By doing this, your PCP
can see someone else
•
Schedule
another appointment
What If I Need To See A Specialist?
If you need to see a Specialist or other provider:
•
You
should ask for a referral from your PCP
•
Your
PCP will give the specialist a referral
If you see a specialist or other provider without a
referral from your PCP, Pro Care may not pay for the service and you may be
responsible for the bill.
Can I See a Non-Pro Care Health Care Provider?
In some cases, your PCP may refer you to a doctor who is
not in our network. These services will sometimes be paid for by us. Your PCP
will arrange the referral. You are allowed to use non-network health care
providers when all of the following apply:
•
Services
cannot be provided to you by a Pro Care provider
•
Services
are medically necessary, and
•
Services
have been approved in writing, in advance by Pro Care
How Can I Keep a Continuity of Care?
If your PCP is no longer part of our network or if you are
a new member and your current provider is not in our network, you will have to
choose a new PCP for your routine care.
If you see a specialist who is no longer part of our
network, you may be able to keep seeing that doctor. To do so, the doctor must
agree to keep seeing you and one of the following must apply:
o
You
are in an ongoing course of treatment, or
o
You
are in your 2nd or 3rd trimester of pregnancy or
o
You
are dying
The amount of time that you can keep seeing that doctor
depends on which applies. Call Member Services if you have any questions about
your PCP.
When
you are out of your county or the State of Michigan and have a medical
emergency:
•
You may go to the
nearest hospital without prior authorization
•
Call your PCP for a
referral for all other out of area medical care needs
•
If your PCP is not
available, call Pro Care at 1-313-267-0300 (local) or 1-877-255-3055 (toll
free)
If
you move out of the Pro Care service area, call your DHS worker. You should
also contact Pro Care to let us know that you have moved. You may have to pick
a new health plan. Pro Care will continue to care for you until the new health
plan begins.
When
you need a referral ask your PCP. In order for your specialty care to be
covered, please remember:
•
You must need the
medical care
•
Your PCP must approve
your visit to a specialist or other provider
•
You must have a
referral
•
A referral from your
PCP is also necessary for all follow-up care after emergency treatment
•
Your PCP will also
arrange for a second opinion if it is needed
If
you need more information, call Member Services. We:
•
Check all referrals
•
Nurses can help with referrals
and authorizations
When
you need services that are not available within our network, your PCP will ask
us for permission to refer you to an out-of-plan specialist or provider. We
will help arrange all related care. If you see a specialist or other provider
without a referral from your PCP, we may not pay for the service and you may be
responsible for the bill.
An
emergency condition is a condition that is so serious or life threatening that
any delay might cause death or permanent impairment. If you have an emergency
condition:
•
Go to the nearest
emergency room or call 9-1-1
•
You do not have to call
Pro Care or your PCP
•
Some examples of
emergency conditions are:
* Heart attack *
Gunshot wounds
* Stroke *
Shortness of breath
* Severe burns *
Heavy bleeding
* Poisoning *
Overdose
•
If
you have an urgent question, call your PCP or Pro Care at 1-313-267-0300
(local) or 1-877-255-3055 (toll free) for help 24 hours a day, 7 days a week.
•
If you do not
have an emergency condition, DO NOT GO TO THE EMERGENCY ROOM. Here are some examples of non-emergency conditions:
* Sore throat *
Flu
* Back Pain *
Colds
* Rashes *
Minor injuries
* Cut & Minor wounds
•
If you go to
the Emergency Room and you do not have an emergency condition, you may have to
pay for the cost of the Emergency Room visit
•
Call
your PCP if you are not sure if you have an emergency condition and he/she will
decide if your condition can be treated in the office. If you cannot get in
touch with your PCP, call Pro Care at 1-313-267-0300 (local) or 1-877-255-3055 (toll free).
Remember,
you must contact Pro Care within 24 hours after you have gone to the emergency
room.
SERVICES and BENEFITS
Which Services Are Covered?
The following is a list of services covered by Pro Care.
Some of these services may need a referral from your PCP before you can get
them. If you have any questions about these services, ask your PCP or call
Member Services.
·
Ambulance
and other emergency medical transportation
·
Blood
lead testing in accordance with Medicaid EPSDT policy
·
Certified
nurse midwife services
·
Certified
pediatric and family nurse practitioner services
·
Chiropractic
services
·
Diagnostic
lab, x-ray and other imaging services
·
Durable
medical equipment and supplies
·
Emergency
services
·
End
Stage Renal Disease services
·
Family
planning services
·
Health
education
·
Hearing
& speech services
·
Hearing
aids
·
Home
Health services
·
Hospice
services (If requested by the enrollee)
·
Immunizations
·
Inpatient
and outpatient hospital services
·
Intermittent
or short-term restorative or rehabilitative (in a nursing facility) up to 45
days
·
Restorative
or rehabilitative services (in a place of service other than a nursing
facility)
·
Maternal
and Infant Health Program (MIHP)
·
Medically
necessary weight reduction services
·
Mental
health care - 20 outpatient visits per calendar year
·
Out-of-state
services authorized by Pro Care
·
Outreach
for included services, especially, pregnancy related and well-child care
·
Parenting
and birthing classes
·
Pharmacy
services
·
Podiatry
services
·
Practitioners'
services
·
Prosthetics
& orthotics
·
Therapies,
(speech, language, physical, occupational)
·
Transplant
services
·
Transportation
·
Treatment
for sexually transmitted disease (STD)
·
Vision
services
·
Well
child/EPSDT for persons up to the age of 21 years
What
Services Are Covered by Medicaid (not Pro Care Health Plan)?
The following is a list of medical services that Pro Care will
not pay for but they are still covered because you qualify for Medicaid.
Use your mihealth card for these services. Talk with your PCP and/or your DHS
caseworker about these services.
·
Dental
Services
·
Services
given by a school district and billed through the school district
·
Inpatient
hospital psychiatric services
·
Outpatient
partial hospitalization psychiatric care
·
Mental
health services over 20 outpatient visits each calendar year
·
Services
given to persons with developmental disabilities and billed through local
mental health agencies
·
Custodial
care in a nursing facility
·
Home
and community based waiver program services
·
Personal
care or home health aide services
·
Substance
abuse services
·
TBI
Program Services
·
Intermittent
or short term restorative or rehab services (in a nursing facility) after 45
days
·
Transportation
for services not covered by Pro Care
·
Elective
abortions and related services
·
Experimental
or investigational drugs, procedures or equipment
·
Elective
cosmetic surgery
What Health Education Programs Do We
Have?
We want you to
stay healthy. We have health education programs such as:
•
Mom
and Babies
•
Diabetes
•
Stop
Smoking
•
High
Blood Pressure
•
Stress
If you would like
a listing of all available topics, please call us at 1-313-267-0300
(local) or 1-877-255-3055 (toll free).
Can I Have Help With My
Transportation?
If you have a
medical emergency, call 9-1-1. Pro Care will provide scheduled non-emergency
transportation for you to get medically necessary care.
If you need
non-emergency transportation such as a ride to get to your doctor’s
appointment, please call us at 1-313-267-0300 (local) or 1-877-255-3055 (toll free). We will need:
o
Time
to set up your ride
o
Current
address
o
Address
of doctor / appointment
It is important that you call us as
soon as you can. We will help arrange transportation if you qualify for this
service.
You may receive family planning
services from:
•
Your
PCP
•
Other
providers such as another doctor, a nurse practitioner, a family planning
clinic, or your local health department
You do not have
to receive a referral from your PCP to see another provider for family
planning. Remember:
o
Pro
Care will pay for these services
o
Family
Planning Services are for men and women
o
These
services include counseling, exams, supplies and birth control
o
You
may also get treatment for sexually transmitted diseases (STD)
o
It
does not include abortion services or infertility treatment
How Do I Get Hospital Care?
There are two types of hospital care:
•
Inpatient
hospital care means that you have to stay in the hospital overnight or longer
•
Outpatient
hospital care is when you go to the hospital for a test or surgery but do not
stay overnight
If inpatient hospital care is necessary:
o Your PCP will
contact Pro Care and arrange for your admission to a hospital Participating
Provider
For outpatient hospital care:
o You will need a
referral from your PCP
Communicable
Diseases - What If I Have A Disease That I Caught From Someone Else?
You do not need a referral from your PCP to go to a local
health department to get treatment. This service includes treatment for:
o HIV/AIDS
o Sexually
transmitted diseases
o Tuberculosis
(TB), and
o Any diseases
which are vaccine-preventable
If diagnostic tests, labs or x-rays are medically
necessary:
•
Your
PCP will authorize and arrange for them to be done by Participating Providers
Call Member Services if you have any questions.
Pro Care covers durable medical equipment (equipment that
can be used for a long time) and medical supplies (supplies that cannot be
re-used) when medically necessary. Some example of covered medically necessary
equipment and supplies are:
·
Wheelchairs
·
Crutches
·
Diabetic
supplies
·
Oxygen
·
Incontinence
Supplies
To get durable medical equipment and supplies:
•
Your
PCP will prescribe the equipment or supplies that you need (i.e. wheelchair,
hospital bed, oxygen)
•
You
must get durable medical equipment or supplies from providers who participate
with us
•
Participating
Providers for durable medical equipment are listed in Pro Care’s Provider
Directory. If you have questions or need help call us at 1-313-267-0300
(local) or 1-877-255-3055 (toll free)
•
Pro
Care covers all equipment and medical supplies except for experimental or
investigational equipment
We cover routine eye examinations, lenses and frames. You
can visit any of the locations in the Provider Directory to get your vision
services and check-ups
If you need a list of Participating Providers call us at 1-313-267-0300
(local) or 1-877-255-3055 (toll free).
What
If I Need Pharmacy Services?
Pro
Care covers certain prescription drugs that your doctor feels you need. Pro
Care has a formulary that your doctor will use to prescribe your drugs. The
formulary is a list of generic and brand name drugs that Pro Care feels give
the best results. There are many drugs on the formulary and if you would like
to get a copy of the formulary, call Member Services and a copy will be sent to
you. The formulary is also on our website at www.procarehp.com. Remember:
o
Your
PCP will decide if and when you need a drug
o
Your
PCP will give you a prescription to get the drug(s) you need
o
We
have a list of covered and non-covered drugs
o
There
are many drugs that your PCP must call us to get approved before you can get
them
o
You
will need to show both your Pro Care ID card and your Medicaid mihealth card
when you go to the pharmacy
o
Drugs
that are paid for by Pro Care do not have a co-pay
o
Pro
Care also covers the following over-the-counter products:
·
insulin
syringes
·
reagent
strips
·
psyllium
·
aspirin
·
condoms
o
Pro
Care does not have co-pays. But some drugs are paid for by the State of Michigan, not Pro Care. If you need to have these drugs you will have a $1.00 co-pay for
each prescription or refill, if you are age 21 or older. Brand name drugs have
a $3.00 co-pay
If the
pharmacist has any questions or concerns (including co-pay concerns), then ask
him/her to call us at 313-267-0300 (local) or 1-877-255-3055 (toll free).
There are many local pharmacies in our network. Please
look in the Provider Directory for the pharmacy nearest you. Call us at
1-313-267-0300 (local) or 1-877-255-3055 (toll free) if you:
•
Have
any questions about your prescription drug coverage or
•
You wish to get a
copy of the list of covered and non-covered drugs (or check our website www.procarehp.com)
What
If I Need Outpatient Mental Health Services?
We cover up to 20 visits per year for outpatient mental
health services. Remember that:
•
You
do not need a referral from your PCP to get in-network mental health services
•
Other
outpatient mental health services may be covered under the Medicaid Program
•
Our
Provider Directory lists mental health providers
•
Call
us and we can help you find an in-network provider
•
If
you have any questions about what mental health services are covered, talk to
your PCP or call us at 1-313-267-0300 (local) or 1-877-255-3055 (toll free). If you have a mental health
emergency, go to the nearest emergency room
There are many signs that may show that you have a drug or
alcohol problem. Some of these may be:
•
drinking
alcohol every day
•
using
illegal drugs
•
no
memory of what happened after drinking or using drugs
•
using
money on drugs or alcohol instead of for food
•
having
unusual behaviors like the sweats, trembling or staggering
•
not
being able to stop using alcohol or taking drugs by yourself
If you think you may have a substance abuse problem it is
very important that you talk to a substance abuse provider to find out how you
can get help
These services may include screening and detoxification,
counseling, and methadone treatment.
For information on how to get the services you need, call
us at 1-313-267-0300
(local) or 1-877-255-3055 (toll free) and Pro Care can get you a number to call for help.
What
Do I Need To Do To Get Hospice (End of Life) Services?
Pro Care covers hospice care. Your PCP can help you get
hospice care or you can call Member Services.
What
Do I Do If I Am Pregnant??
If you think that you are pregnant call your PCP right away
and have a pregnancy test.
When you are sure you are going to have a baby:
•
Your
PCP can help you choose a maternity provider
•
It
is important for the health of your baby to see your maternity provider as
early as possible. Don’t
delay!
•
Regular
check-ups by your doctor during pregnancy are necessary to make sure you have a
healthy baby
•
Your
doctor can answer any questions you may have about your pregnancy. Pro Care
pays for:
o check-ups before
the baby is born
o delivery services
and hospital care
o check-ups after
the baby is born
After your baby is born you must:
•