Member Handbook. A guide for all Blue Cross Complete members. complete of Michigan. Includes:

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1 Blue Cross complete of Michigan Confidence comes with every card. Member Handbook A guide for all Blue Cross Complete members Includes: Preferred Drug List and Specialty Drug Guide Guidelines to Good Health Certificate of Coverage

2 Contact us Customer Service Customer Service is available whenever you have a question or concern about benefits or services. Customer Service can answer your questions, help you understand your benefits and give you information about our policies. If you need care after hours, we can help you find urgent or emergency care. Call toll free: (TTY users should call ) 24 hours a day, seven days a week Pharmacy Customer Service Call toll free: (TTY users should call ) 8:30 a.m. to 6 p.m. Monday through Friday Write to us: Blue Cross Complete of Michigan Suite Galleria Officentre Southfield, MI Visit us online: MiBlueCrossComplete.com Download our mobile app Download our mobile app by visiting the GoogleTM Play or Apple App Store. Type BCCMI in the search bar. Other important phone numbers 24-hour Nurse Help Line (TTY: ) Anti-fraud Unit (TTY: 711) Bright Start maternity program (TTY: ) Outreach Team (TTY: ) (health education and resources) Tobacco quit program (TTY: ) Transportation (TTY: 711) Healthy Michigan Plan members: Learn about more phone numbers for you in Part 5: Healthy Michigan Plan, including Dental Customer Service. The Healthy Michigan Plan is a health care program from the Michigan Department of Health and Human Services. Blue Cross Complete administers Healthy Michigan Plan benefits to eligible members. MI Child program (TTY: ) Michigan Enrolls or Language Services Please call Customer Service if you need free help in another language or format. If you d like to speak in another language, or need help reading or understanding a document, we can help. We can even help you in another language when you re at your doctor s office. Written materials may be available in other formats. Necesidades especiales Por favor, llame a Servicio al Cliente si necesita ayuda en otro idioma o formato. Si desea hablar en otro idioma, o necesita ayuda para leer o entender un documento, le podemos ayudar. Incluso le podemos ayudar en otro idioma cuando está en el consultorio de su médico. Los materiales impresos pueden estar disponibles en otros formatos. االاحتيیاجاتت االخاصة االرجاء االاتصالل بخدمة االعملاء ا إذذاا كنت تحتاجج مساعدةة مجانيیة بلغة ا أخرىى ا أوو شكل ا آخر. ا إذذاا كنت تريید االتحدثث بلغة ا أخرىى ا أوو تحتاجج مساعدةة لقرااءةة ا أوو فهھم ووثيیقة يیمكننا االمساعدةة. يیمكننا ا أيیضا مساعدتك بلغة ا أخرىى عندما تكونن في مكتب ططبيیبك. يیمكن توفر االمواادد االمكتوبة با شكالل ا أخرىى.

3 Welcome to Blue Cross Complete of Michigan Blue Cross Complete is one of many plans affiliated with Blue Cross Blue Shield of Michigan. You now carry the most widely recognized health care symbols the Blue Cross and the Blue Shield. Thank you for choosing us to be part of your health care team. We partner with you and your doctor to make sure you get the health care you need, when you need it. This handbook explains your health plan benefits. It includes your member materials: Blue Cross Complete Member Handbook: This explains your covered benefits and medicines, picking a doctor, getting preventive care, living with chronic conditions and more. Preferred Drug List and Specialty Drug Guide: These are the medicines we cover. Certificate of Coverage: This is your health care contract with us. Getting started Choose a doctor to be your primary care physician. You must have a primary care doctor in our network to use your benefits. If your current doctor is in our network, tell us his or her name. If you d like to choose or change doctors, call Customer Service. If you don t choose a doctor, we ll choose one for you. Make an appointment with your primary care doctor for a well visit. Read through this handbook. It explains how your plan works. You ll read about your benefits, getting and staying healthy, our policies and other information about our health plan. Healthy Michigan Plan members: Learn more about your plan in Part 5: Healthy Michigan Plan. After joining Blue Cross Complete and picking a primary care doctor, you should: Call for an appointment with your primary care doctor within 60 days, or at about two months. See your doctor for this appointment within 150 days, or at about five months. During this visit, you ll complete a Health Risk Assessment form, and then every year. If you have any questions, please contact us. We look forward to serving you. About Blue Cross Complete Blue Cross Complete of Michigan LLC is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross Complete is a state-approved Medicaid health maintenance organization. Please note: Blue Cross Complete is not contracting as the agent of the Blue Cross and Blue Shield Association. No person, entity or organization other than Blue Cross Complete will be held accountable or liable to you for any of Blue Cross Complete s obligations created under the contract. Blue Cross Complete is solely responsible for its own debts and other obligations. 1

4 Table of contents Part 1: Your Blue Cross Complete health plan... 4 How to choose a doctor, make an appointment and get care. Your Blue Cross Complete ID card... 4 Getting primary and specialty care... 5 After hours, hospital and follow-up care... 6 Choosing a doctor... 9 Part 4: Prescription benefits Read about your drug benefits, including generic medicines, filling a prescription, finding a pharmacy and the medicines we cover. Medicines covered by Blue Cross Complete Medicines covered by the state of Michigan Preferred Drug List Specialty Drug Guide Appointments Copays and reimbursements Our commitments to you Part 2: Your tools and resources Use our online tools and resources to change your doctor, get claims and billing history, see your virtual ID card and find doctors and hospitals. Part 5: Guidelines to good health Learn more about preventive health care, including recommended tests and screenings, healthy behaviors and important health numbers you should always know. Health information to support your health goals Guidelines to good health Your online account Member mobile application Part 3: Your health care benefits What s covered by Blue Cross Complete and the state of Michigan. What s covered by Blue Cross Complete Extra help and health programs What s covered by the state of Michigan An overview of your Blue Cross Complete coverage and benefits Part 6: Healthy Michigan Plan Additional information for Blue Cross Complete members enrolled through the state of Michigan s Healthy Michigan Plan. About the Healthy Michigan Plan Your Blue Cross Complete member ID card What the Healthy Michigan Plan covers How the Healthy Michigan Plan works Paying your cost sharing Supplemental Certificate of Coverage for Healthy Michigan Plan members

5 Part 7: MIChild Information for members enrolled through the state s MIChild plan. Part 11: Your privacy How we handle your private and confidential information. Notice of nondiscrimination Part 8: Update your personal records What to do when your family size changes and how to tell us your wishes for medical care, such as life support. If your family changes Make your wishes known: Advance directives Multi-language interpreter services Part 12: Notice of nondiscrimination and language services We comply with federal nondiscrimination and language services laws Notice of nondiscrimination Multi-language interpreter services Part 9: Your rights and responsibilities To get the most from your health care, follow these rights and responsibilities. Member rights Part 13: Our Board of Managers The Blue Cross Complete Board of Managers helps adopt and put in place the policies that say how Blue Cross Complete runs. Member responsibilities Help identify health care fraud Certificate of Coverage Part 10: If you have a concern What to do if you have a complaint or would like to appeal a medical decision. Grievances and appeals

6 Part 1: Your Blue Cross Complete health plan Your Blue Cross Complete ID card You must show your Blue Cross ID card each time you visit your doctor or a hospital. You will also need it to fill prescriptions. It s different from your mihealth card. Always keep both cards with you. If you lose your Blue Cross Complete card, call Customer Service right away. Your ID card Enrollee Name: Your name Enrollee ID: Identifies your record in our files Beneficiary ID: Number assigned to you by the state Group Number: Shows the group in which you re enrolled Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday 5 6 RxBIN & RxPCN: Drug plan numbers Rx: Shows you have drug coverage MiBlueCrossComplete.com Your card may look slightly different. Blue Cross Complete of Michigan LLC An in d ep en d en t licen see o f t h e Blu e Cr o ss an d Blue Shield Association Hospital and medical claims Providers in Michigan, file claims with: Blue Cross Complete P.O. Box 7355 London, KY Providers outside Michigan, file claims with your local BCBS plan. Out-of-state services are covered only in an emergency or when authorized by Blue Cross Complete. Pharmacy claims: P.O. Box 516 Essington, PA PerformRx Pharmacy Benefits Administrator Customer Service Blue Cross Complete: TTY/TDD: PerformRx: TTY/TDD: Mental health/substance abuse treatment: Providers Only: Medical authorizations and inquiries: Pharmacy authorizations and inquiries: Misuse may result in prosecution. If you suspect fraud: Use of this card is subject to terms of applicable contracts and certificates. Healthy Michigan Plan members: Learn more about your ID card in Part 5: Healthy Michigan Plan. On the back of your ID card, you ll find: Toll-free Customer Service numbers and other important numbers. MH-03/Rev1/19/17 4

7 Getting primary and specialty care Primary care To use your Blue Cross Complete benefits, you choose a primary care physician who will be your health care partner. A primary care physician is your personal doctor. This is your health care partner who will manage all of your health care needs. Your personal doctor cares about you, and you can talk to him or her about your health. Build a relationship with your personal doctor. He or she is the first doctor you see when you have health concerns. He or she will help you when you are sick and help you get healthy and stay well. Call your primary care doctor first for all your health care needs. These include routine check-ups, illness or an injury that needs prompt attention. Coordination of care Your personal doctor is responsible for overseeing your care. If you or your child sees more than one doctor, such as a specialist or mental health provider, tell your personal doctor. He or she should know about your care with other providers. Learn more about after-hours care, such as urgent and emergency care, in After hours, hospital and follow-up care in this section. Your doctors work with each other to make sure your care is safe and effective. Your doctor may need information from your other doctors to make sure you are getting the care you need. It s OK to ask your doctor if he or she knows about your recent care and if he or she has recent updates from your other providers. Obstetrics and gynecology Women: You may get routine obstetrics and gynecology care from your primary care doctor. You may also get other women s health services from any network provider. You don t need a referral. You can see a Blue Cross Complete obstetrician or gynecologist for routine care, such as office visits and Pap tests, without a referral. You can do this even if your obstetrician or gynecologist isn t your primary care doctor. Pregnant women: You may be able to see an out-of-network provider without a referral. If you are pregnant or think you are pregnant, it s very important to see a doctor right away. Learn more about healthy pregnancies in Part 4: Guidelines to good health. Customer Service can help you schedule a prenatal appointment. They can also give you more information about extra services that may be available for parents and baby. Getting the care you need helps you and your baby stay healthy. Pediatrics Children: Your child can see a Blue Cross Complete pediatrician without a referral. Your child can do this even if your child s pediatrician isn t his or her primary care doctor. Blue Cross Complete members under age 18 may have a pediatrician or another doctor as their primary care doctor. This could be a family doctor or general practitioner. If your child s doctor isn t a pediatrician, your child may still see a pediatrician without a referral. Visit our website at mibluecrosscomplete.com 5

8 Specialty care You may need medical care that your primary care doctor can t provide. He or she may ask you to see a specialist. A specialist is a doctor with training in a specific area of medicine, such as a cardiologist a doctor who checks the heart. You can get specialty care from a Blue Cross Complete provider without a referral. Sometimes a specialist may be your primary care doctor. If you, your Blue Cross Complete doctor and your specialist think a specialist should be your primary care doctor, call Customer Service. You can also choose a nurse practitioner as your primary care doctor. Health care provided through a Managed Health System Blue Cross Complete contracts with managed health systems. If you receive care from a managed health system, you should select a primary care doctor who participates with that health system. You should work directly with your primary care doctor for a referral for any service received outside of your primary doctor s office. State and federal health centers Child and Adolescent Health Centers Child and Adolescent Health Centers are state health care centers for children and teens. Most children under age 21 can also get health care at these centers. You do not need a referral. For help finding a center, visit our online provider directory at mibluecrosscomplete.com. Federally Qualified Health Centers FQHCs are community-based organizations that provide health care services. You have a right to access medical and behavioral health services at an FQHC in your county. To find an FQHC near you, call Customer Service. After hours, hospital and follow-up care If you need nonemergency care outside of normal business hours, call your doctor first. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday 24-hour Nurse Help Line hours a day, seven days a week He or she may make special arrangements for you. Your doctor may send you to an urgent care center or to another provider. If you re unable to reach your doctor, you can call Customer Service. You may also call our 24-hour Nurse Help Line. Urgent and after-hours care Urgent care centers and after-hours clinics are helpful if you need care quickly but can t see your primary care doctor. You don t need a referral or prior authorization to go to an urgent care center or after hours-clinic in our network. These places can treat illnesses that should be cared for within 48 hours, such as the flu, high fevers or a sore throat. They can also treat ear infections, eye irritations and low back pain. If you fell and have a sprain or pain, it can be treated at an urgent care center. If you aren t sure if you need urgent care, call your doctor. He or she may be able to treat you in his or her office. 6

9 Hospital care Emergencies and nonemergencies Emergency care You are covered in the state of Michigan for emergency services. You don t need a referral or prior authorization to get emergency care. Blue Cross Complete does not cover any medical services received outside of the United States.! If you have an emergency and delaying your care to call your primary care doctor may cause permanent damage to your health, get care first. Go to the nearest emergency room or call 911. You may go to any emergency facility. A medical emergency means if you don t get immediate medical attention: Your health, or the health of your unborn baby (if you re pregnant), may be in danger. Your body functions may be seriously damaged. Any organ or part of your body may not work properly again. Emergency conditions may include: Severe pain Unusual chest pain Problems breathing Puncture wounds Nonstop bleeding Broken bones Severe bites or burns Blows to the head Sudden loss of strength or feeling in the arms or legs Emergency services are: Given by a provider who is qualified Needed to evaluate or stabilize an emergency Once you are in stable condition after an emergency, you may need more care to get better or to fix your condition. This is called poststabilization. If you receive emergency care at an out-of-network hospital or facility, Blue Cross Complete may transfer you to a network hospital when it is safe to do so. We cover non-emergent ambulance transportation.! If you have a medical emergency when you are outside the Blue Cross Complete service area, call 911 or get help at the nearest medical facility. Learn more about transportation in Part 2: Your health care benefits. Visit our website at mibluecrosscomplete.com 7

10 Nonemergency care You may go to the hospital for other services that aren t an emergency, such as surgeries, to have a baby or for some tests. Some inpatient and outpatient nonemergency services must be provided at a Blue Cross Complete network hospital. You may need prior authorization. If needed, your doctor can assist you in getting prior authorization. The right care at the right time If you feel the sniffles or flu coming on, you may only need a trip to your doctor s office or an urgent care clinic. But what if it s an emergency? To help you decide the best place to get care, see the chart below. It shows examples of urgent and emergency care. You can also call your doctor or our 24-hour Nurse Help Line.! In an emergency, don t delay go to the nearest emergency room or call 911. Nonemergency Call your doctor or go to an urgent care center for: Emergency Go to the ER or call 911 for: Minor sore throat Earache Minor cuts and scrapes Sprains and strains Fever under 103º F Colds and flu Broken bones or severe sprains Deep cuts or uncontrolled bleeding Poisoning Severe burns Chest pain or sudden severe pain Fever over 103º F Coughing or vomiting blood Sudden dizziness, weakness, loss of coordination or balance, or loss of consciousness Numbness in face, arm or leg Seizures Difficulty breathing Sudden blurred vision or sudden severe or unusual headache Follow-up care Follow-up care helps you get the care you need after a trip to the urgent care or ER. Follow up with your primary care doctor so he or she can make sure you get the right follow-up care and services. 24-hour Nurse Help Line hours a day, seven days a week Did you know? You can see a network OB-GYN without a referral. After urgent or emergency medical care, follow up with your primary care doctor within 24 hours. If you were in the hospital for mental health care, follow up with your mental health or primary care doctor within seven days. Your provider will help you get any extra care you may need. 8

11 Choosing a doctor We have providers for all your health care needs, and our network gives you access to some of Michigan s top doctors and facilities. You may choose and see any of the primary care doctors or specialists in our network. Finding a provider If the doctor you have now is in our network, he or she can be your Blue Cross Complete doctor. If your current doctor isn t in the Blue Cross Complete network, you must choose a Blue Cross Complete doctor. For help choosing your doctor, call Customer Service. Our online provider search Maybe you prefer a doctor who speaks a certain language or who is from a background or culture similar to yours. You may want to choose a doctor who is close to your home. Maybe you need a doctor who has evening or weekend hours. The best place to start looking for a doctor is on our website. Our online provider search includes our network doctors, specialists and facilities. For our primary care doctors, the search also includes any foreign languages the doctor speaks and if he or she is accepting new patients. You can also download and use our member mobile app to find a doctor. To get the mobile app, visit the Google TM Play or Apple App Store. Search for the Blue Cross Complete mobile app by typing BCCMI in the search bar. The app is available for free. You can also call Customer Service to get this information or to have it mailed to you. Customer Service can also help you choose or change your primary care doctor or find a different provider. Changing your primary care doctor To use your Blue Cross Complete benefits, a primary care doctor will be assigned to you when you enroll. The name and contact information for your doctor will appear on your ID card carrier. Your ID card carrier will be mailed to you. This primary care doctor will be your health care partner. This is your personal doctor. This doctor will manage all of your health care needs. Your personal doctor cares about you, and you can talk to him or her about your health. If you d like to change your doctor, please call Customer Service. Build a relationship with your doctor. He or she is the first doctor to see you when you have health concerns. He or she will help you when you are sick and help you get healthy and stay well. Call your primary care doctor first for all of your health care needs. These include routine check-ups, illness or an injury that needs prompt attention. If it s after hours or you can t get in to see your doctor, go to an urgent care center. In a life-threatening emergency, go to the nearest ER or call 911. If your doctor leaves our network Sometimes doctors leave our network. If your doctor leaves, we ll let you know. You ll need to pick a new doctor. If you are pregnant or have a terminal illness, you may be able to continue treatment with your doctor for a short period of time, even after he or she leaves our network. This is called continuity of care. If you would like us to consider continuity of care for you, please call Customer Service. 9 Visit us online: MiBlueCrossComplete.com Get the app. SEARCH BCCMI. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday Visit our website at mibluecrosscomplete.com

12 Your request will be reviewed. The decision will be based on your condition. You can also call Customer Service for help finding a new doctor. Out-of-network services and prior authorization You must get most of your care from providers in our provider network. You can see any doctor in our network without a referral. Customer Service can help you find providers in our network. Out-of-network services Blue Cross Complete must approve of any out-of-network services before you get them. If a Blue Cross Complete doctor is unable to provide these services, Blue Cross Complete will cover the services by an out-of-network doctor with prior authorization. A prior authorization is not required for urgent care or emergency medical services. We ll cover them until a network doctor can provide them. Prior authorization Sometimes, Blue Cross Complete needs to give permission for you to get some services. This is called prior authorization. Work with your doctor to see if an authorization has been given. Or, call Customer Service to make sure you have the authorization you need. You can see any doctor in our network without prior authorization. You must have prior authorization to see a provider who is not in our network, even if he or she is in our service area. If you re traveling, we may cover medically necessary, emergency services with prior authorization. Medical services received outside of the United States are not covered by Blue Cross Complete. A financial incentive is not given to Blue Cross Complete staff who deny authorizations. Appointments To see your doctor, you ll need an appointment. You can call for after hours and emergency transportation. Call our ride service at Making an appointment To make an appointment, call your doctor s office. Have your Blue Cross Complete ID card ready. Tell the staff if you are a new or existing patient as well as the kind of appointment you need. You may be making an appointment for a well visit or because you re sick. This helps the doctor s staff make the right kind of appointment for you. If you re a new patient, also tell them you re a Blue Cross Complete member and confirm that the doctor is a network provider. Make sure the doctor is seeing new patients, and confirm the office location and hours. Ask how to get in touch with the doctor in an emergency. The office staff will find a date and time for your appointment. Take your Blue Cross ID card with you. If you need help getting to your doctor s office, call our ride service at from 8 a.m. to 5:30 p.m. Monday through Friday. Learn more about transportation in Part 2: Your health care benefits. Changing or canceling an appointment Call your doctor as soon as possible if you need to change or cancel your appointment. Most offices prefer that, when possible, you cancel at least 24 hours before your appointment time. 10

13 Getting care and appointments When and where you get care matters. That s because your doctor s office, urgent care centers and emergency rooms have different resources for specific kinds of care. Don t forget that regular visits with your doctor help you get the best care. These charts show how soon you should be able to get an appointment for certain kinds of care. Unless it s an emergency, make appointments with your primary care doctor. Medical health services Type of visit Description Standard scheduling times Learn more about urgent and emergency care in After hours and follow-up care in this section. Preventive care (primary and specialty care) Routine care Urgent care Emergency care A health history and exam. Includes screenings and shots listed in the Guidelines to Good Health. For women, this includes your annual gynecology exam. Conditions that are not sudden or not life threatening, or symptoms that keep coming back, such as rashes and joint or muscle pain. Or, conditions that need ongoing care. Sudden but not life-threatening conditions, such as fever greater than 101 degrees lasting for more than 24 hours, vomiting that persists, mild diarrhea or a new skin rash. A condition that is life threatening or requires immediate help. 30 calendar days 10 calendar days Within 48 hours Right away Mental health services Type of visit Description Standard scheduling times Routine care Cases where no danger is found and your ability to cope is not in danger. Within 10 business days Urgent care Emergency care (not life threatening) Emergency care (life threatening) Conditions that are not life threatening, but face-to-face contact is needed quickly, such as anxiety or panic attacks. Conditions that require rapid help to prevent a decline in your state of mind that, if left untreated, could put your safety at risk. Conditions that require immediate help to prevent death or serious harm to yourself or others. Within 48 hours Within 6 hours Right away Did you know? Your child can see a network pediatrician without a referral. Visit our website at mibluecrosscomplete.com 11

14 Copays and reimbursements Copayments Most Blue Cross Complete members do not pay copays for covered services. You shouldn t have to pay when getting services covered by Blue Cross Complete. Other services from the state of Michigan, such as those listed in Part 2: Your health care benefits, may have a small copay. Please call your Department of Human Services case worker for information. Healthy Michigan Plan members: Healthy Michigan Plan members have cost sharing, including copays and contributions. Learn more about cost-sharing in Part 5: Healthy Michigan Plan and the Healthy Michigan Plan Certificate of Coverage. Blue Cross Complete members shouldn t get any bills for covered services from providers. They will bill Blue Cross Complete for the covered medical services you receive. If you get a bill from a provider, you can send the bill to Blue Cross Complete to review. Reimbursements You may get emergency or other authorized care outside our service area, including out of the state. If you do, you may need to pay for the services and ask Blue Cross Complete to pay you back, also called reimbursement. To be reimbursed, you must send us a form, your bills and payment receipts. Customer Service can send you the forms and give you information. Emergency care costs: To ask us to reimburse emergency care costs you paid, fill out and complete a Member Claim Reimbursement form. Customer Service can mail you this form. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday Travel costs: To ask us to reimburse approved travel costs for medical care, including meals and lodging, fill out and complete a Travel, Meals and Lodging Reimbursement form. Customer Service can mail you this form. They can also answer any questions you have before you travel and tell you about our policies. Work with your case manager to help coordinate meals and lodging. Call Customer Service before you make your travel plans. Pharmacy costs: To ask us to reimburse prescription costs you paid, fill out and complete a Prescription Drug Reimbursement form. Pharmacy Customer Service can mail you this form. When you get your form, please follow the instructions and complete the form. Return the form to us with the information requested. If Blue Cross Complete does not pay the claim, we will tell you why. Please send your form and information within either: 90 days of when you receive the bill or One year after the date you received the service If your claim is denied, you have rights to appeal the decision. Learn more about appeals in Part 8: If you have a concern. Call Customer Service if you have questions about your care, covered services, how to use your benefits or how we pay doctors. 12

15 Our commitments to you Blue Cross Complete and other members of your health care team want you to get the right care at the right time. This means you get the care and services you need to stay healthy, when you need them. We take action to make sure the care you get meets your needs and national care standards. We also want to make sure you can get information about how we re doing and how well our programs are working to meet these standards. Getting the right care at the right time To make sure we re supporting your access to the right care at the right time, we set and follow certain rules and guidelines. We work to remove barriers to care and service. Our decisions about your use of health care are made based only on your need and health coverage. We do not reward health care providers or others to deny coverage. We do not pay complex care management staff to make decisions to give you less care than you need. We do not hire, promote or end our relationships with health care providers and others based on if they will or may support denying care or services. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday We re proud that our health management programs and other practices help you and other members get healthier and stay that way. These programs and practices also support our mission to provide you efficient and appropriate care in a timely manner the right care at the right time. Quality improvement programs Our quality improvement programs help doctors give you appropriate care. This handbook gives you information about these programs and our clinical practice guidelines. To request this information, call Customer Service. You can ask for information about our: HEDIS scores CAHPS scores Clinical practice guidelines Outreach Team a.m. to 6:30 p.m. Monday through Friday Quality Improvement program, which includes our goals and progress For disease and health information on topics like taking care of your asthma, and tips for healthy eating, call our Outreach Team. Visit our website at mibluecrosscomplete.com 13

16 Part 2: Your tools and resources Your online account Your online account is a secure website that can help you stay connected with Blue Cross Complete of Michigan. It has most of your recent health history. And it s easy to use. To find your online account, go to MiBlueCrossComplete.com on your computer. It s easy to create an account. All you need is about five minutes and your Blue Cross Complete ID card. There are more benefits of using your online account. Take a health assessment.* This is a health questionnaire that can help you find possible health risks. It will give you tools you can use to help manage those risks. It only takes a few minutes. The results will tell you how to control those risks. This important information can make a big difference in your life. Read a variety of health articles. This information can help you learn how to live a healthy life. Get claims and billing history. Change your primary care doctor. You can change your primary care doctor at any time. Get benefit details. Get up to six months of your prescription history, find the locations of in network pharmacies, and more. Member mobile application The Blue Cross Complete mobile app keeps you up to date on your health care information. Here s what you can do with the app: See your virtual member ID card Find doctors and hospitals Call Customer Service and our 24 hour Nurse Helpline Get directions to doctors offices Keep your account information updated Get the app. SEARCH BCCMI. The mobile app is available for iphone and Android smartphones. Visit Google TM Play or the Apple App Store. It s free to download. Simply type BCCMI in the search bar. If you use an iphone, make sure it runs ios or better. For Android users, your phone needs to run version 5.0 or better. 14

17 Part 3: Your health care benefits You re a Blue Cross Complete member. Most of your health care is covered by Blue Cross Complete, but you may get some care and services from the state of Michigan. This section will help you understand what services are covered and how to get them. What s covered by Blue Cross Complete We want to help you get, stay and be healthy. And that means health care benefits that give you the care you need, when you need it. Blue Cross Complete members have a wide range of benefits, such as: Health care such as doctor s visits, vaccines and more Medical supplies, such as diabetes test strips Learn more about your drug coverage for prescriptions in Part 3: Prescription benefits. Urgent and emergency care Medicines We also have many free programs to help you and your family live healthy. Maybe you need extra help when you are sick or living with a chronic condition such as asthma, diabetes or heart disease. Or maybe you re a soon-to-be or new mom. We have programs for you and your kids, too. This section provides an overview of your benefits. Any rules about your benefits, such as how often you can get some services, and details about all covered services are in the Certificate of Coverage. Learn about benefits from the state of Michigan in What s covered by the state of Michigan in this section. Always check your certificate or call Customer Service if you have questions about any of your benefits. Understanding your certificate helps you make the most of your benefits. It can also help you make decisions about care that may not be covered. Healthy Michigan Plan members: You have all the benefits of Blue Cross Complete. You also have additional benefits and responsibilities. Learn more in Part 5: Healthy Michigan Plan. Preventive and medical care We want you to get and stay well. To help you do that, we cover many preventive and routine medical services, and offer health education programs. We cover: Doctor and specialist visits, including visits to chiropractors, podiatrists and nurse practitioners Learn more about all your benefits in the Certificate of Coverage at the back of this book. Regular or annual well visits Vaccines Lab work, X-rays and other imaging services Allergy testing, treatment and injections Family planning, including birth control Visit our website at mibluecrosscomplete.com 15

18 HIV/AIDS testing and treatment of sexually transmitted diseases Services you may get at Federally Qualified Health Centers Health education programs, including disease management and tobacco cessation Nutritional counseling for members with certain conditions, such as heart failure, diabetes or prediabetes, high body mass index and more Medically necessary weight reduction services Emergency and urgent care services Rehabilitative therapy, including cardiac rehab, physical, speech and occupational therapies Hospital and surgical care When you need extra care or have an emergency, we cover most hospital care, surgery and lab work. This includes: Outpatient surgical services (this is when you don t stay overnight at a hospital) Chemotherapy and other drug treatments for cancer Dialysis and treatment of kidney disease, including end-stage renal disease Cost of a shared hospital room Lab work, X-rays, imaging services, therapies and other medical supplies while you re in the hospital Surgeries, including organ transplants Home health care, skilled nursing services and hospice care Sometimes, you may need long-term care. To help you get the care you need, we may cover: Short-term nursing home services (long-term care is provided by the state of Michigan) Home health care services for members who are homebound Supplies and equipment related to home health care Hospice care Special note: Hospice care must be approved and arranged by your primary care doctor and Blue Cross Complete. Care must take place in the Blue Cross Complete service area. Did you know? Talk to a nurse anytime. We have a free 24-hour Nurse Help Line. 16

19 Durable medical equipment Some medical conditions need special equipment. Durable medical equipment we cover includes: Equipment such as nebulizers, catheters, crutches, wheelchairs and other devices Disposable medical supplies, such as ostomy supplies, peak flow meters and alcohol pads Diabetes supplies, such as lancets, test strips, insulin needles, blood glucose meters and insulin pumps Prosthetics and orthotics Special note: Prosthetics replace a missing body part, such as a hand or leg. They may also help the body function. Orthotics correct, align or support body parts that may be deformed. To get durable medical equipment, you need a prescription from your doctor. You also need authorization from Blue Cross Complete. You must get your item from a network provider. To find network durable medical equipment providers, call Customer Service or use our online search. Vision, hearing and dental Vision: Eye care is an important part of your overall health. To make sure your eyes are healthy and help you see the best you can, we cover: Routine eye exams A pair of glasses Replacement glasses if your glasses are lost or broken Retinal eye exams for members with diabetes Special note: You don t need a referral for retinal exams. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday The services must be from a network vision center. For a list of network eye doctors and vision centers, call Customer Service or use our online provider search. Dental: The Healthy Kids Dental program is available statewide to all members up to age 20. Enrollment is automatic. Those enrolled will get a permanent Delta Dental identification card that has your Medicaid ID number. Call Dental Customer Service with questions at Dental Customer Service is available Monday through Thursday, 9 a.m. until 5 p.m. and Friday, 9 a.m. until 3:30 p.m. Visit us online: MiBlueCrossComplete.com or download our mobile app For help finding a in-network dentist in your area, visit our website at mibluecrosscomplete.com and click on Find a Doctor. Hearing: How well you hear affects your quality of life. We help you hear the best you can by covering: Hearing exams for all members Hearing aids for members under age 21 and Healthy Michigan Plan members SEARCH BCCMI. Healthy Michigan Plan members: Learn more about your hearing aid benefits in Part 5: Healthy Michigan Plan. To find a network hearing provider, call Customer Service or use our online provider search. Visit our website at mibluecrosscomplete.com 17

20 Dental care: Your oral health says a lot about your overall health. Any member under age 21 or his or her parent or guardian can call Customer Service to find a dentist. If you are age 21 or over, see What s provided by Healthy Kids Dental in this section. Blue Cross Complete may cover oral surgery in some situations. Healthy Michigan Plan members: Some dental services are covered by Blue Cross Complete. Learn more about your dental benefits in Part 5: Healthy Michigan Plan. Mental health services We want you to feel your best, including your mental health and emotional feelings. To help you, we cover short-term mental health care, up to 20 outpatient visits a year. These visits may be with a network therapist, such as a counselor, licensed clinical social worker or psychologist. More mental health care and services, such as long-term mental health care and substance use disorder, may be covered by the state of Michigan. Learn more in What s covered by the state of Michigan. Customer Service can help you find a network mental health provider or you can use our online search. Or, you can call a network provider directly. You do not need a referral.! If you need emergency care for a life-threatening condition, or if you re having thoughts of suicide or death, go to the nearest emergency room or call 911. Help is available for you now. Transportation Since we know how important your health care is, we want it to be easy for you to get to your appointments and pick up your medicines. Use our free ride service to get to nonemergency covered services such as: Ongoing or regular doctor s visits or sick visits and other medical care Pharmacies to pick up your prescriptions Durable medical equipment suppliers to pick up your medical supplies Transportation To get a ride, call our ride service. We ll help you find the best kind of ride for your health condition and appointment type. Please remember to schedule two days in advance. If you need to cancel a ride, call four hours ahead of your appointment. Gas reimbursement and bus pass reimbursement are also provided by Blue Cross Complete. Rides for nonmedical services aren t covered. For emergency transportation, always call 911. We also cover emergency transportation, such as ambulances. Your doctor or care provider will arrange for other covered transportation, such as: Transfers between hospitals, including by ambulance Ambulance transportation between a skilled nursing facility and hospital 18

21 Care for women Women have special health needs. To make sure you get the care you need to be at your best for you and your family, we also cover: Family planning Pregnancy testing Birth control and birth control counseling HIV/AIDS testing and treatment of sexually transmitted diseases Pregnancy and maternity care, including the Maternal Infant Health Program Prenatal and postpartum care Midwife services in a health care setting Delivery care Parenting and birthing classes Mammograms and breast cancer services, such as treatment and reconstruction Pap tests 24-hour Nurse Help Line hours a day, seven days a week Family planning may include counseling about when to start a family or what size of family is best for you. It may also include education about birth control and other services. Family planning clinics can also write prescriptions for birth control. You can get family planning services from any doctor, clinic or health department. You don t need a referral. Customer Service can help you find a family planning clinic. Care for children and teens The health care children and teens get shapes their adult health habits. To help your child or teen younger than age 21 to be as healthy as he or she can be, we also cover: Regular well visits and follow-up care Physical exams and developmental screening Childhood vaccines Testing for lead poisoning Services you may get at Child and Adolescent Health Centers Early Periodic Screening Diagnosis and Treatment program services Hearing exams and hearing aids Eye exams and glasses Oral health screening and fluoride treatment Outreach Team a.m. to 5:30 p.m. Monday through Friday Visit our website at mibluecrosscomplete.com 19

22 Extra help and health programs To help you get and stay in your best health, we offer many free programs to give you the education and support you need. We have programs for children, adults and new or soon-to-be moms. Our Outreach Team can help you learn more about these programs. They can answer your questions or help you join these free programs. Outreach Team We have a team of nurses and other staff to support your health needs. Our Outreach Team can give you health information, help you with a chronic condition, help you get medical supplies and more. 24-hour Nurse Help Line Our free 24-hour Nurse Help Line can help you get answers to your health questions right away. It is a confidential service just for you. The nurse line can help you make informed health care choices when your doctor is not available. Early Periodic Screening, Diagnosis and Treatment program (EPSDT) To make sure children and young adults who qualify get the medical care they need, Medicaid created the Early Periodic Screening, Diagnosis and Treatment program. EPSDT is Medicaid s health coverage for children and teens. Blue Cross Complete of Michigan provides EPSDT services. For members under age 21, an annual exam may include several of these services: Physical and developmental exams, including autism screening Height and weight Blood pressure test Hearing, vision and dental tests Vaccines Lead screening Cholesterol screening, as needed Behavioral health, developmental and special services Outreach Team a.m. to 5:30 p.m. Monday through Friday 24-hour Nurse Help Line hours a day, seven days a week Your doctor may also talk to you about your or your child s health, nutrition and other health topics. He or she may also refer you to other services and resources. Children s Special Health Care Services Program If your child has a serious, chronic medical condition, he or she may be eligible for Children s Special Health Care Services. CSHCS provides extra support for children and some adults who have special health care needs. This is in addition to the medical care and care coordination from Blue Cross Complete. Did you know? Get where you re going. Our free ride service can help you get to your covered services. There is no cost for this program. It doesn t change your child s Blue Cross Complete benefits, service or doctors. CSHCS provides services and resources through the following agencies. 20

23 MDHHS Family Center for Children and Youth with Special Health Care Needs: This center provides a parent support network and training programs. It may also provide financial help for conferences about special needs and more. If you have questions about this program, call the CSHCS Family Phone Line at from 8 a.m. to 5 p.m. Monday through Friday. County health departments: Your county health department can help you find local resources. These may include parent support groups, adult transition help, childcare, vaccines and more. For help finding your local county health department, visit your county s website, michigan.gov or mibluecrosscomplete.com. You can also call Customer Service. Children s Special Needs Fund: The Children s Special Needs Fund helps families get items not covered by Medicaid or CSHCS. These items promote the health, mobility and development of your child. They may include wheelchair ramps, van lifts and mobility equipment. To see if you quality for help from this fund call Customer Service can answer your questions about EPSDT and CSHCS. Disease management If you have a chronic medical condition such as diabetes or heart disease, we ll enroll you in our free disease management programs. We ll send you health education materials to help you understand and manage your health. We have programs for members with asthma, COPD, diabetes, heart disease and heart failure. To request these services, call Customer Service. Complex care management If you are seriously ill or injured, we can give you the extra help and support you need through complex care management. This program has the information, tools and help you need to make good health care choices and make the most of your benefits if you are very sick. Customer Service hours a day, seven days a week Pharmacy Customer Service :30 a.m. to 6 p.m. Monday through Friday Your personal complex care management is handled by complex care management nurses. Care managers are registered nurses who understand all parts of the health care system. Many have training in specific diseases and are certified in case management. Your nurse works with you, your doctor, and other healthcare providers and specialists to coordinate your health care. Your nurse is a great resource when you have questions about your care. All the information we discuss with you or your doctor is confidential. You may call Blue Cross Complete Rapid Response Outreach Team at If a care manager isn t available, you can leave a message. A care manager will call you back within two business days. Your ongoing care will be coordinated by a care manager who ll be contacting you. If you need help with your care needs before your care manager contacts you again, please call You ll remain enrolled in the program while you re a member of Blue Cross Complete. Visit our website at mibluecrosscomplete.com 21