Welcome to HAP. We re here to help.

Transcription

1 Member Handbook

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3 Welcome to HAP. We re here to help. 1

4 About Your Health Plan What is an HMO? HMO stands for health maintenance organization. All of your care is arranged through a personal care physician (PCP) whom you can select. Your PCP will provide your covered preventive care, keep your medical history and help you choose a specialist when you need one. While you can refer yourself to some in-network specialists, such as an allergist or a dermatologist, you will need a referral from your PCP in order to get specialty care. You are covered worldwide for emergency and urgent care. You do not have coverage for care received outside of your PCP s network. What is a PPO? PPO stands for preferred provider organization. You don t have to select a PCP with a PPO plan. However, you can use a PCP to help you navigate your health services. This way, you receive the most complete care possible. When you belong to a PPO plan, you are covered for preventive services and specialty care received from an affiliated provider. If you decide to use a specialty provider who is not affiliated, you may pay higher out-of-pocket costs. What is an EPO? The exclusive provider organization, also known as an EPO, offers the freedom of our PPO but without the out-of-network benefits. You will not have to choose a PCP as a member of this plan. You may see any doctor or specialist within the EPO network, without a referral. EPO members (excluding NationCare) can also access our statewide network throughout the state of Michigan. The statewide network is a combination of HAP, Alliance and the ASR Physicians Care Network. Outside of the state of Michigan, you can access Cigna providers per your contract. What is a Self-Funded HMO? A Self-Funded HMO is a health plan that operates like an HMO, but the coverage received for medical, drugs and other services is paid for by the employer instead of the insurance contract. 2 This brochure contains general information about your health plan. Please refer to your plan documents for benefit details. To view your plan documents, log in at hap.org or request a copy by calling Customer Service.

5 We re Here to Help We are here for you. If you have a question, we have an answer. Our knowledgeable and friendly Customer Service specialists are here for you no matter how you choose to contact us. We like to learn about the times when things are going well. But we know, in spite of our best efforts, things may not always go as well as they could. We encourage you to submit a complaint or compliment to us. We take the time to listen to your feedback, and most problems can be resolved quickly. Your Personal Service Coordinator Learning all of the ins and outs of a new health plan can be challenging. So we make it easy for you. As a new member, we introduce you to your very own personal service coordinator, who is dedicated to assisting you for the first two years of your membership. Think of your personal service coordinator as your health plan guide, who can explain how to get the care you need and make the most of your benefits and coverage. Your personal service coordinator can help you choose your PCP, register online at hap.org or get information about your health plan benefits. Call us if you have a: HMO plan: (800) , TDD (800) Monday through Friday, 7 a.m. to 7 p.m. Saturday, 8 a.m. to noon PPO or EPO plan: (888) , TDD (800) Monday through Friday, 8 a.m. to 5 p.m. Saturday, 8 a.m. to noon Self-Funded HMO plan: (866) , TDD (800) Monday through Friday, 7 a.m. to 7 p.m. Saturday, 8 a.m. to noon HAP Personal Alliance plan: HMO: (800) , TDD (800) PPO: (800) , TDD (800) Monday through Friday, 8 a.m. to 8 p.m. Saturday, 8 a.m. to noon. FEHBP* members: (800) , TDD (800) Monday through Friday, 8 a.m. to 8 p.m. Saturday, 8 a.m. to noon Automated Services Line (all plans): (877) hours, seven days a week Write to us if you have a: HMO or Self-Funded HMO plan: HAP ATTN: Customer Service 2850 W. Grand Blvd. Detroit, MI PPO, EPO or HAP Personal Alliance plan: Alliance Health and Life Insurance Company ATTN: Customer Service 2850 W. Grand Blvd. Detroit, MI us through hap.org: Log in at hap.org and select Send & Receive Messages. Any message sent this way is safe and secure. We respond during normal business hours. Visit us in person: Detroit Lobby Monday through Friday, 8:30 a.m. to 4:30 p.m W. Grand Blvd. Detroit, MI Southfield Lobby Monday through Friday, 8:30 a.m. to 4:30 p.m Northwestern Highway Southfield, MI Help in Other Languages If you re more comfortable with a language other than English, call Customer Service (numbers listed at left) to arrange for translation services. This is a free service. *Federal Employees Health Benefits Program 3

6 Cost-Sharing Responsibilities Cost-sharing responsibilities are set out-of-pocket costs. This means that you will pay for designated portions of your covered care through copays, coinsurance and deductibles, and/or through payroll deductions that fund a part of the premium costs. There are three main types of cost-sharing that you may need to pay: Deductible A deductible is the fixed amount that you will pay before your health benefits cover your medical services. After this deductible is met, covered services are payable at an allowable charge. For example, let s say you have a $500 deductible based on the plan you chose. Once you ve paid $500 out of pocket for medical services, your health plan benefits will begin to cover your costs, and you ll only pay portions of your bills with copays and coinsurance. Copay A copay is a flat-rate payment made each time you receive certain health care services, such as visiting your doctor, seeing a specialist or picking up a prescription at the pharmacy. Copays do not count toward the deductible. You will continue to pay copays after you have met your deductible, until you reach your out-of-pocket limit. This does not apply to grandfathered plans. Coinsurance Instead of a flat-rate copay, coinsurance is a percentage that you pay when you receive a covered service. For example, if your plan states that it will pay 80 percent of allowable charges for covered services (after your deductible and/or copays have been met), then the remaining 20 percent is the coinsurance amount you will pay. Out-of-Pocket Limit In some cases, you may be required to pay no more than a maximum dollar amount in coinsurance, copays and deductibles during a particular period. This amount is known as an out-of-pocket limit (maximum). Once it is reached, your plan pays 100 percent of covered services less any cost-sharing responsibilities. The out-of-pocket limit never includes your monthly premium or noncovered services. These amounts are specific to your benefit package. This information is found in your plan documents. You can view your plan documents when you are logged in at hap.org. If you have questions about cost-sharing responsibilities or want to request a copy of your plan documents, please call Customer Service. 4

7 What s Covered? As you begin to use your benefits and coverage, the question often comes up, What s covered?. We want you to know how to fully access the care you need. Your health plan documents are your primary source of truth when it comes to what is actually a covered benefit on your plan. To view your plan documents, log in at hap.org or contact Customer Service. Your plan broadly covers preventive and medically necessary health care services and supplies if: They are approved by your health plan or your health plan administrator Your doctor approves them (HMO/Self-Funded HMO plans only) They are required in an emergency or urgent care setting In general, your plan does not cover any service that is not medically necessary, such as: Cooking, bathing and other activities of daily living Long-term care Private-duty nursing Private rooms Liposuction Cosmetic surgery, such as breast enhancement (unless mastectomy has been performed) Experimental services Investigative services HMO/Self-Funded HMO plans only: Care that is not approved by your PCP will not be covered. Some exceptions may apply, such as OB/GYN and behavioral health services. See your plan documents for a complete listing. For a complete list of covered and noncovered services, refer to your health plan documents. For a copy of these documents, contact Customer Service. You can also log in at hap.org to see if a service is covered and what your cost-sharing amount might be. Log in and choose Procedure Lookup. Then enter the procedure code supplied by your doctor. 5

8 Filing Claims Providers bill the health plan directly. Whenever you visit a provider, you will pay only your costsharing amounts. If you get a bill that isn t for your cost-sharing amounts, please let us know right away and send us the bill. You should not get bills from providers for medical charges beyond your control. For example, if you get care from a non-affiliated provider in an emergency, this is beyond your control. This is called hold harmless. If you receive a bill, send it to us for possible reimbursement. Please be sure to get a detailed bill from the provider that includes the following: Patient s name and ID card number Date of service(s) Dollar amount charged for each service Procedure and diagnosis codes (you can get these from the provider) Provider s name, address and tax identification number If you aren t sure of any of the above information, ask the provider who performed the service. Complete information on the claim form will help with timely processing. Requests for claims reimbursement should be submitted within 90 days of the date of service, if possible, to: Claims Division Member Reimbursement 2850 W. Grand Blvd. Detroit, MI Explanation of Benefits You may get an Explanation of Benefits (EOB) in the mail after your claim is processed. The EOB will show your copay or coinsurance amounts, the eligible amounts applied to your deductible and any services that were not covered. You can also view your EOB when you log in at hap.org. The EOB is not a bill but an explanation of how your claim was processed. If you have questions about your EOB or how a claim was paid, call Customer Service. You may also get claim processing details by logging in at hap.org. Filing an Appeal, Grievance or Complaint You have the right to appeal decisions made regarding your benefits, claims or billing, including requesting an External Independent Review that is allowed under the Patient s Right to Independent Review Act. You also have the right to file a complaint if you are dissatisfied with the manner in which we provide services (see page 3: We re Here to Help). Our Appeal and Grievance Policy outlines the process you may use to seek resolution if you feel dissatisfied with the services, benefits and/or policies of HAP or its providers. To view our Appeal and Grievance Policy, log in at hap.org or request a copy by calling Customer Service. 6

9 Service Area Our HMO and Self-Funded HMO plans are approved by the state of Michigan to provide services in a ninecounty area, including Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair and Washtenaw. Most hospitals in this area are affiliated with us. Except for emergency and urgent care, you do not have coverage for out-of-plan services. If you have an HMO or a Self-Funded HMO and are outside of your plan s service area, preventive services are not covered. Our PPO and EPO plans are approved to cover health care services statewide in Michigan. Coverage While Traveling Remember, your plan covers urgent and emergency care worldwide. But if you ever become ill or injured while traveling more than 100 miles away from home, or outside the U.S., one call can connect you to our partner Assist America, a 24/7 operations center. Assist America arranges and pays for all the services it provides, including emergency medical evacuation, compassionate visits and medical consultation. For a complete listing of Assist America s services, call (800) or visit On the go? You can also use the Assist America mobile app for iphone and Android. You ll get instant access to one-touch calling to our 24/7 Emergency Operations Center, pharmacy locator and more. Prescriptions While Traveling Check your prescriptions before you leave home. If your medications are low, be sure to get a refill. We also have a national network of pharmacies to use while traveling, including Kmart, Rite Aid, Target, Walgreens, Walmart and CVS. 7

10 Students Away at School Program If your child (age 5 to 26) goes away to school outside our service area, we go with him or her. Emergency Care for Students Away Emergency care is covered. There s no need for authorization. If there s a serious illness or injury, the student should call 911 or go to the nearest emergency room. If admitted to the hospital, this student or someone chosen on his/her behalf must report the admission. Call Admissions using the number on the back of your ID card within 48 hours. Without proper notice, claims for these services may be denied. Urgent Care for Students Away Urgent care for treatment of minor injuries like a sprained ankle or treatment of the flu is also covered. This includes X-rays and lab tests following an illness or injury, done in an outpatient setting. Looking for an urgent care center? Call Customer Service to find out if there is an affiliated urgent care center nearby. If there isn t, the student should go to the nearest urgent care center. College health care centers can also help with urgent care services. Follow-Up Care for Students Away Follow-up care must be authorized by your health plan before the student gets treatment. It may also need review by our medical director. Call Customer Service for more information. Hospitalization for Students Away If the student is admitted to the hospital, our Admissions department must be notified within 48 hours. We reserve the right to transfer a member to an alternate facility if deemed necessary for continued care. 8

11 Coverage for Students Away Here is a list of some covered services for the Students Away at School Program: Emergency and urgent care Required maintenance visits for chronic conditions with the preapproval of our medical director or designee Follow-up office visit related to an acute illness/injury only with the preapproval of our medical director or designee Imaging provided in the outpatient setting and related to acute illness or injury Laboratory tests provided in the outpatient setting and related to acute illness or injury Routine immunizations/vaccines, according to the recommendations from the Centers for Disease Control and Prevention Allergy injections Prescription coverage as allowed under the member s prescription drug rider, if applicable The services identified as covered services for the Students Away at School Program will be covered at the in-network level. See your plan documents for specific details about your coverage. The following services are not covered under the Students Away at School Program: Routine complete physical examinations, including gynecological exams All elective surgeries or hospitalizations Routine eye examinations and/or eyeglasses (optometry and optical services) Routine OB/GYN services for pregnancy Physician visits or physical therapy, occupational therapy, or other therapies or treatments that do not have a prior authorization from your health plan Vaccines administered for the sole purpose of travel The Students Away at School Program does not cover dependent members permanently residing out of our service area even if the dependent is a student. Any services other than those listed under Covered Services are not covered. Your plan does not cover dependent children who live with a custodial parent outside of our service area. For questions about the Students Away at School Program, including questions about coverage, authorizations and referrals, call Customer Service. 9

12 Selecting Your Doctor A personal care physician (PCP) is a plan-affiliated doctor who is usually an internist, general or family practitioner, or pediatrician. Whether or not your plan requires you to choose a PCP, we believe it is an excellent idea to have a PCP as a go-to doctor. The relationship you have with your PCP is important because he/she is the person who knows your complete medical history and will make sure you get the care you need. HMO and Self-Funded HMO plans Members of our HMO and Self-Funded HMO plans must select a PCP. When you need specialty care, your PCP has all of the right connections and will refer you to a qualified specialist. You and your family members do not need to have the same PCP. If you choose a PCP in the Henry Ford, ACCESS or Genesys network, you will get specialty care from doctors within that network. If you choose a PCP in any of our other networks, you may see specialists in any HAP network. PPO and EPO plans PPO and EPO plan members do not need to choose a PCP. However, we do recommend that you choose a primary doctor to keep your baseline medical history and help you access the care you need. Our Customer Service specialists can help you find a primary doctor or specialist based on your needs. Since choosing a doctor is an important decision, we offer several ways to help you: Contact your personal service coordinator View doctor profiles, maps and driving directions online at hap.org. Compare up to three doctors in a side-by-side view that highlights education, residency, certification, gender, languages spoken and hospital admitting privileges Use our Automated Services Line, 24 hours a day, seven days a week, at (877) using our PCP ID codes from our Provider Directory. View our provider directories online at hap.org HMO and Self-Funded HMO plan members can call a PCP selection specialist 8 a.m. to 6 p.m. Monday through Friday at (888) PPO and EPO plan members can call Customer Service for help selecting a doctor 10

13 Changing Doctors As an HMO or Self-Funded HMO member, you may change your PCP when you need to, as often as you need to, for any reason, unless you are hospitalized. To change PCPs, use one of the same ways you used to choose your first PCP. Some things to remember: PCP changes are effective the same day if staying in the same network PCP changes are effective the first day of the next month if changing networks. For example, a transfer request received anytime in March to another network will be effective April 1 Keep seeing your current PCP until the effective date of transfer Transitioning Your Child to Adult Care When your child reaches age 18, it s time to start thinking about transitioning him/her from a pediatrician to an adult provider for medical care. If you would like help selecting a provider for your young adult, contact Customer Service. 11

14 Visiting Your Doctor s Office After you select your doctor, schedule an initial appointment so he/she may learn of any previous conditions and be better able to treat you should you need care. During this first visit, be prepared to discuss your family and personal medical history. Helpful ideas when you visit your doctor: Prepare a list of topics, health concerns and questions Talk openly about your overall health Be sure to bring along all medicines (including vitamins and supplements) you take Find out how and when to receive care by asking about: Medical center/doctor office hours When to schedule other checkups How to schedule same-day or next-day appointments for urgent medical conditions (if available) How to obtain medical care or advice if the office is closed Your Role as a Patient You and your doctor are both committed to your health. Your doctor will respect your choices, and it s important that you show him/her the same respect. When you work together, receiving proper medical care is a much better experience. A healthy relationship with your doctor can be harmed, however, if you fail to respect your doctor s ability to provide medical care. So it s important to follow your doctor s directions. Discuss any concerns you may have in a respectful manner. Just as it s your right to change doctors if you re unhappy, your doctor can decide to end your doctor/patient relationship with him/her. Canceling Appointments Some doctors may charge a fee for missed appointments or those not canceled 24 hours in advance. Any charges resulting from missed appointments are your responsibility to pay. Your health plan does not cover these charges. Ask your doctor about his/her policy. 12

15 Prior Authorization/Precertification Prior authorization/precertification is a review process that ensures you meet the criteria for elective or emergency admissions before going into the hospital. All elective admissions need prior authorization/precertification before you receive services such as hospital, skilled nursing facility, hospice and behavioral health. If you are admitted to a hospital that isn t affiliated with us, we will call the doctor treating you to check your status and your care plan. When it is safe, you may be transferred to an affiliated hospital. If you refuse to be transferred, your care at the non-affiliated hospital will be covered at a reduced benefit level. Hospital Services If hospital services are needed, such as inpatient care and treatment, please notify us by calling the number on the back of your ID card. This call will serve as your prior authorization/precertification before you are admitted into the hospital. Continuity of Care If you re in an active course of treatment with a non-affiliated doctor, we provide continuity of care. This means we will work with you and your doctor to move your care to one of our doctors when it is safe to do so. Here s how it works: 1. You can continue to see your current doctor for regular visits to track your condition and to receive direct treatment 2. Your current doctor will prescribe your medicines and monitor your treatment plan 3. One of our nurses will call you and your health care provider to talk about the diagnosis, history and current treatment plan, reviewing the information and coordinating care with your doctor 4. We will move you to an affiliated provider when it is safe to do so To get things started, call Customer Service. When you call, be sure to have this information handy so we can send it to our medical team: Your name, address and telephone number Your ID number Active coverage date The name, address and telephone number of the doctor who is currently treating you 13

16 Understanding Where to Go for Care Some doctor visits should be scheduled even when you re feeling just fine. Others need to be scheduled when you have a medical problem or concern. Sometimes a health issue comes up unexpectedly. These problems can vary in degree of urgency. Additionally, your out-of-pocket costs can vary greatly depending on the type of care you require. That s why knowing where to go for care is important. Emergency Room, Urgent Care or My PCP? Knowing the difference between emergency room (ER) and urgent care can save you a lot of time and money. Visits to the ER usually cost more than visits to an urgent care clinic. If a medical condition is life or limb threatening, or if you have severe wounds, visiting an ER makes sense. But if the medical condition is not life threatening (a sprained ankle, needing stitches), visiting a nearby urgent care clinic may save you time and money. Urgent care clinics are staffed by doctors and are open after normal business hours, and finding one near you is easy. When it s not an emergency, there are other just as effective options that are often less expensive, such as: Same- or Next-Day Appointments Your PCP s office often sets aside same- or next-day appointments for urgent care needs Call your doctor s office for its urgent care guidelines Using an Urgent Care Center Keep a list of urgent care centers handy along with their hours of operation Visit hap.org/urgentcare to find a full list of urgent care options If you or a loved one experiences a true emergency, or if you are not sure where to go based on your symptoms, go to the nearest ER or call 911 for help. Use the charts on the following pages as tools to help you decide which option will work best for you and your family. 14

17 Symptoms: Where do I go if I have... Back pain Mild asthma Minor headache Sprain, strain Nausea, vomiting, diarrhea Bumps, cuts, scrapes Cough, sore throat Ear or sinus pain Eye swelling, irritation, redness or pain Minor allergic reaction Minor fever, colds Rash, minor bumps Stitches Minor burn Sudden or unexplained loss of consciousness Signs of heart attack, such as sudden/severe chest pain Signs of stroke, such as numbness of the face, arm or leg on one side of the body; difficulty talking; sudden loss of vision Severe shortness of breath High fever with stiff neck, mental confusion and/or difficulty breathing Coughing up or vomiting blood Cut or wound that won t stop bleeding Poisoning Trauma to the head Suicidal feelings Partial or total amputation of a limb PCP Urgent Care Emergency Room This is not a complete list of conditions. These are examples only. If you believe you are having an emergency, call 911 immediately or go to the nearest emergency room. The information provided is intended to be general information, and is provided for educational purposes only. It is not intended to take the place of examination, treatment or consultation with a doctor. Health Alliance Plan urges you to contact your doctor with any questions you may have about a medical condition. 15

18 Services: Where do I go if I need... Care Needed Where to Go Wait Time from Phone Call to Visit Notes Well Visits/ Annual Exams Routine checkups scheduled at regular times, such as once a year PCP or your doctor s office Within 30 days Routine Office Visits Non-urgent office visits with mild symptoms, like a sore throat PCP or your doctor s office Within 4 days After-Hours Care Care needed outside of your PCP s or doctor s office s normal business hours Call your doctor s office to find out where to seek care or how to get in touch with a nurse or doctor. You may also go to an affiliated urgent care center Urgent Care Serious but nonemergency injury or illness, like sprained ankles and minor wounds PCP or your doctor s office or any affiliated urgent care center Same or next day Go to hap.org/urgentcare or call Customer Service for a list of affiliated urgent care centers. You can use any affiliated urgent care center. Check your ID card for any cost-sharing amounts Emergency Care An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm Go to the nearest emergency room immediately or call 911 You can get emergency care right away, 24 hours a day, seven days a week, at any emergency room worldwide If you are admitted to a hospital not affiliated with us after an emergency, be sure to call the number on the back of your ID card within 48 hours to ensure payment for services. You may be transferred to an affiliated hospital when you are stable. If you decide to refuse the transfer, you will be responsible for payment for your care Specialty Care: HMO and Self-Funded HMO Plans Appointments with specialists for care not provided by your PCP Call your PCP first for a recommendation Talk to your PCP first in order to schedule an appointment with a specialist. Your PCP has good working relationships with many highly qualified specialists. If you choose a PCP in the Henry Ford, ACCESS or Genesys network, you will get specialty care from doctors within that network. If you choose a PCP in any of our other networks, you may be able to see specialists in any HAP network. HMO plan members do not have out-of-plan coverage Specialty Care: PPO, EPO and POS Plans Appointments with specialists for care not provided by your doctor The specialist your doctor recommends or you choose We recommend that you see a specialist after calling your PCP or doctor first, but it s not required. Remember, EPO members don t have out-of-plan coverage 16

19 Women s Health Female members can seek OB/GYN services from any plan-affiliated doctor without a referral. Services can include: Pelvic exams and Pap tests Breast exam or mammogram All prenatal visits Standard lab tests Ultrasound Care for a health problem that requires several visits, such as appointments after surgery Inpatient OB/GYN care Deliveries Your doctor may still seek authorization for some OB/GYN services. Breast Reconstruction Women who have had mastectomies are eligible for certain breast reconstruction benefits. We offer coverage for: Reconstruction of a breast surgically removed by a mastectomy Surgery on and reconstruction of the other breast as needed to provide a symmetrical look Prosthetics Treating problems arising from any part of the mastectomy, including swelling of the surrounding tissue after surgery Coordinated Behavioral Health Management We offer help for those who have mental health and/or substance abuse (alcohol and drug) disorders. You have the same confidentiality rights with our Coordinated Behavioral Health Management (CBHM) team as you do with a doctor or nurse. No referral is required for routine outpatient behavioral health treatment services when provided by a planaffiliated provider. We also offer case management services for behavioral disorders, education for specific diagnoses and help in managing your condition. It s important to remember that you must get all care from affiliated health care providers. You can choose a behavioral medicine provider from the Provider Directory on hap.org, or our CBHM team can help with finding a qualified specialist for both evaluation and treatment. Call us at (800) , Monday through Friday, from 8 a.m. to 5 p.m. Nonemergency calls are returned within 24 hours. If you need emergency behavioral health care, go to the nearest emergency room or call

20 Privacy Pledge We are committed to ensuring the privacy and security of your personal protected health information (PHI). We define PHI as any information that can be used to identify you and relates to your past, present or future physical or mental health condition. It also includes any payment you ve made or received for health care. Your information is only available to HAP employees, on a need-to-know basis, and only when necessary to facilitate your care. We have guidelines and safety measures in place to protect your information and keep it safe. We protect your PHI whether it is written, spoken or in electronic form by requiring employees and others who handle your information to follow specific confidentiality and technology usage policies. To request a copy of HAP s Privacy Policy, call Customer Service or visit hap.org/privacy. Important Legislation GINA It sounds like this law is named after someone, but it in fact stands for Genetic Information Nondiscrimination Act. Passed in 2008, this law protects people against unfair treatment because of DNA traits that raise their chances of getting certain illnesses. It means health insurers can t refuse coverage to a woman whose DNA suggests she s at higher-than-average risk for breast cancer, for example. It also means employers can t hire or fire workers based on their DNA information. Michelle s Law Passed in 2010, this law was designed to keep college students from losing their parents group health insurance if they drop out of school because of illness. It s named after Michelle Morse, who became a student health rights advocate after being diagnosed with cancer in her college years. The law says employerprovided health plans must continue coverage for up to one year for a dependent child who is a college student when the child takes a certified medically necessary leave of absence. The Affordable Care Act also makes sure college-age dependents are covered, regardless of student status. 18

21 Prescription Benefits If your plan has a prescription drug rider, you have prescription coverage. We use a drug formulary, which is a list of covered prescription drugs. You can view our formulary and search for your medication at hap.org/prescriptions. We review new medications on an ongoing basis. We may add or remove items from our formulary during the year. The formulary is updated quarterly. This information is available online. Prescription drugs are self-administered drugs that you can obtain from pharmacies. The list of covered prescription drugs is selected in consultation with a team of health care providers and represents the prescription therapies believed to be a necessary part of a quality treatment program. Your health plan will cover the drug listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. In addition to prescription drugs, our formulary includes medical drugs. Medical drugs are covered under your medical coverage, are supplied by your health care provider and are given to you in your doctor s office or health care facility. Drugs provided for home infusion therapy are also considered medical. Please refer to your plan documents for information about your cost-sharing for medical drugs. Covered Medication Facts: You need a prescription medication rider to receive pharmacy benefits Copays and coinsurances for prescriptions are listed in your plan documents and on your ID card Coinsurance for your medical drugs is listed in your plan documents Some covered drugs may have additional requirements or limits on coverage. These are listed on the formulary and may include: Prior Authorization Some medications on our formulary have criteria you must meet before we cover them. This means that you will need to get approval before you fill your prescriptions for these drugs. You may also receive coverage for a medication not included on our formulary or ask us to exempt you from a formulary requirement through the exception process. Your doctor must submit a request indicating why formulary requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us information when requesting either prior authorization or an exception. Step Therapy In some cases, your health plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then consider Drug B. Quantity Limits Certain drugs have quantity limits. A quantity limit is the maximum quantity that can be dispensed per each fill of medication or the maximum number of fills allowed for treatment of certain conditions. Specialty drugs and injectable drugs (except insulin) are limited to a maximum 30-day supply per fill and are available through a specialty pharmacy. Some specialty drugs require a 15-day fill first. 19

22 Generic Drugs When a Food and Drug Administration-approved generic drug is available, your prescription will be filled with the generic form of the medication. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand-name product. Generic drugs cost you and your plan less money than brand-name drugs. Specialty Drugs These are prescription or medical drugs that require close monitoring for safety and efficacy. For this reason, HAP has contracted with Pharmacy Advantage, a specialty pharmacy from which you can obtain specialty drugs. Specialty drugs require prior authorization, and Pharmacy Advantage can help you and your doctor submit a request for prior authorization. You or your doctor can contact Pharmacy Advantage at (800) Maintenance Drugs Your health plan offers select generic drugs that are designated as maintenance because they are commonly used by our members for managing chronic diseases. Members can get these maintenance drugs at most retail pharmacies for a 90-day supply. You can visit hap.org/prescriptions to see if your drug is on the maintenance drug list. You can also get a 90-day supply of most oral medications from our mail-order pharmacy, Pharmacy Advantage. The charge for a 90-day supply is normally two copays, but may vary. Your doctor would need to write your maintenance prescriptions for a 90-day supply. The following are not covered: Over-the-counter (OTC) medications, unless specified on the formulary Dietary food or food supplements Drug products used for cosmetic purposes Experimental drugs and/or any drug products used in an experimental manner Replacement of lost or stolen medication The cost of prescriptions filled at non-plan pharmacies Affiliated Pharmacy Network Most major drugstore chains are in your pharmacy network. This means that you can get your prescriptions easily and quickly. You can visit hap.org and select Find a Pharmacy under the Prescriptions tab to find a retail pharmacy near you. Pharmacy Advantage Home Delivery Service We are affiliated with Pharmacy Advantage Home Delivery Service so that you can refill or renew your prescriptions for a 90-day supply safely and securely online. Prescriptions are delivered in seven to 10 working days by first-class mail. Allow enough time for mailing so that you won t run out of your medicine. For more details, visit or call (800)

23 Online Tools How to Register on hap.org There s a lot waiting for you at hap.org. All you have to do is register. Get your ID number from your card and follow these steps: 1. Go to hap.org 2. Click Register Now 3. Select Member 4. Fill out Member Registration 5. Click Submit Our website is a convenient way to view your plan documents and eligibility information. You can look up your copays, coinsurance or deductibles. Plus, you can check the status of a claim or print a PDF copy of your ID card if you ve lost it. You can also: Send and receive messages Receive health reminders See your pharmacy claim history Look up a prescription drug My Plan The My Plan tab on hap.org has your claims, referral and benefit information. Send and Receive Messages Once you log in at hap.org, you can select Send & Receive Messages to send us questions, concerns, compliments or complaints from a secure site. You will get a response in your hap.org inbox. Only our Customer Service specialists view your messages as needed to provide a response, so your information is secure and private. 21

24 Health Reminders We each have different health care needs based on age, gender and health condition. Based on your claims history, our Health Reminders tell you when immunizations or screenings are due. See the My Health & Wellness tab. My Provider Address Book Save provider or location names, addresses and notes so that you can see them online at any time. See the Find a Doctor/Facility tab. HAP OnTheGo Mobile App Now you can have health plan and health and wellness information in the palm of your hand. HAP OnTheGo is a smartphone app that makes it easy to find a doctor or a nearby facility, download an ID card, check symptoms and manage health conditions. istrive for Better Health We offer istrive for better health to make your health goals easier to reach. This digital health coaching program is free, confidential and personalized just for you. istrive helps you understand your risks and manage your goals and guides you through decisions. When you link to istrive, you will see a variety of online programs that employ easy-to-use aids to achieve your goals every step of the way: Conduct a health risk assessment Manage your weight Eat healthier Deal with stress Quit smoking Lower your blood pressure Lower your cholesterol Manage chronic conditions Manage diabetes Manage back pain Manage pain To get started, log in at hap.org and link to istrive. HAP Advantage HAP Advantage offers discounts on a variety of health and wellness programs, as well as entertainment options and resources. You will enjoy preferred rates and discounts on a variety of health and wellness-related activities and venues, such as Weight Watchers, YMCA and Henry Ford OptimEyes. A complete list of discounts is available at hap.org/advantage. HAP Advantage is a value-added program. This means that the services and products made available under this program are not covered benefits or otherwise payable by your health plan. HAP and its affiliates, agents and assigns make no representations or warranties regarding the quality, price or effectiveness of the services or products or the credentialing of the providers made available by this program. 22

25 New Technology It seems as if there are new ideas in health care every day. From new drugs to tests to services, we hear it all the time. We keep up with these new ideas so you can get the best medical care possible. We make changes to our benefits and coverage based on these developments when needed. Once we know there is something new that isn t a covered benefit, we have our doctors take a very hard and complete look at it. Here s our evaluation process: The doctors find all the facts available to create a full report This information includes evaluations and input from other health care professionals who are topic experts After all the facts are in, the new advancement endures a thorough review to see if it is good for our members At the end, we review the advancement with our Benefit Advisory Committee to confirm if it will become a new benefit Medical professionals review and finalize all benefit policy rulings Our Quality Program Our Quality Management department wants you to know how our Quality Program monitors and improves the health care and services you receive. Much like preventive service guidelines, HEDIS * is an element that is at the heart of our Quality Program. HEDIS, also known as the Healthcare Effectiveness Data and Information Set, describes a comprehensive, standardized set of indicators used to measure the performance of a health plan. Each year, we conduct an extensive analysis that you can use to identify trends, make informed choices about health care and witness HAP s ongoing commitment to improved performance. To view our Quality Program Document, a summary of our overall objectives and progress, log in at hap.org and select the My Health & Wellness tab and click on Quality & Patient Safety. Also available on our website are the preventive service guidelines, a schedule of preventive services to help keep the whole family healthy, as well as updated information on health education classes available in your area. Members without Internet access can contact the Quality Management department at (313) for copies of the online Quality Program materials. *HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). 23

26 Restore CareTrack Program If you have a chronic condition, such as asthma, coronary artery disease or diabetes, we will support your relationship with your doctor free of charge. With Restore CareTrack, you have options to help you take control. They may include: Working one on one with a nurse health coach over the phone An in-home telemedicine monitoring program to help you monitor your medications and condition through daily sessions Behavioral health specialists who will help you identify emotional triggers and behavioral conditions that can affect your physical well-being and ability to follow your doctor s treatment plan A medication review to ensure the right medication and dosage is taken at the right time Restore Case Management Program HAP Restore Case Management is a free program that helps members with the personal support they need. With this program, a registered nurse will work closely with you and your doctor to make sure you re getting the care you need, when you need it. The nurse will be there to help with: Scheduling appointments, such as visits with specialists and treatment facilities Providing a full understanding of your condition(s) Learning how to manage medications Coordinating home visits by working with doctors to schedule home visits with registered nurses and therapists when needed Making sure you get the medical equipment you need Connecting you with community resources that assist with basic everyday needs For more information about HAP s Restore programs or to refer yourself, call (800) You can also refer yourself by logging in to hap.org. Select the My Health & Wellness tab, then choose Restore CareTrack Disease Management Program or Restore Case Management and complete the secure online triage form. Your doctor, family member or caregiver may also refer you to this program. 24

27 Utilization Management Utilization Management (UM) is the method by which we make sure our members get quality care. This means getting the right care at the right time in the right place. We do this by using different review processes (pre-service, urgent concurrent and post-service) at different stages of your care. UM uses proven medical practices from doctors across the country and applies these practices when reviewing your doctor s requests. Case Management used in long-term care and difficult treatment plans. We work with your doctors to measure, plan, coordinate, monitor and review complex care needs. Medical Screening a regular screening process before services happen. This looks at whether the suggested care is right for your condition. Retrospective Care a review of the services after they are provided to assess medical necessity and the provider s billing practices. Prior Authorization/Precertification a review step to help you and your doctor with making choices about your medical care. We review the appropriateness of elective medical services before they are provided to lead you to the right specialist and to avoid repeating diagnostic treatments. Your doctor manages your medical care and is an important part of the prior authorization process. Prior Authorization of Admissions a review process to make sure that a member meets the criteria for elective or emergency admissions before going into the hospital. All hospitals that are contracted with us must call to let us know about your admission. This service is available 24 hours a day, seven days a week. Pledge to Members We continually strive to ensure that you receive all necessary services at the appropriate time and in the appropriate setting. All utilization management decisions are based only on the appropriateness of care and service and the existence of coverage. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care. Furthermore, we do not offer financial incentives to encourage inappropriate underutilization of covered services. If you have questions about these review processes, please call Customer Service. Telecommunication services for the deaf, hard of hearing or those who are unable to speak are available by calling (800) If it is after business hours, please leave a message, and we will return your call the next business day. If needed, we can call on your behalf or connect you with other departments to get your questions answered. 25

28 Doctor Data About Our Credentialing Process We want to make sure you have quality experiences and quality doctors. We make sure all our doctors, PCPs and specialists go through a credentialing process. This process ensures that our education and training standards are met. Credentialing helps you get the most from your health plan. We provide background information about your doctor so you feel confident that you re getting great care. When it s time for you to choose your doctor, you may want more information to help you make an educated choice. Knowing that your doctor has completed all necessary requirements will give you peace of mind. We look at state licenses to make sure that doctors meet our guidelines and those from the state. This information is monitored, and we re-credential our doctors at least every three years. Doctor Compensation Partnering with our doctors includes fair compensation for services. There are two ways our providers receive payment for services: Fee-for-service: Each time you are seen for medical care, a bill is sent to us. The doctor is paid according to a set fee schedule that has been established by us and agreed upon in advance by the doctor. Capitation: The provider is paid a set amount every month regardless of how much care you receive. Both methods are based on actual payment practices used throughout the U.S. Our PPO and EPO providers receive payment for services through a fee-forservice contract. 26

29 Planning Ahead Does your family know what type of care you want in the event of a serious illness? What if you re badly injured in an accident? To prevent your family from facing hard life-and-death choices without your guidance, write your wishes in an advance directive. The durable power of attorney for health care (DPAHC) is a form of the advance directive. You can use this form to tell your doctors and family whom you want to make health care choices for you if you can t do it yourself. Here is what you need to know: Anyone 18 and older should have a plan You can change your representative at any time Have a talk with your doctor and family members about your wishes Make someone a representative now so that everyone knows what kind of care you do or do not wish to receive in the future Get a copy of Know Your Medical Rights by calling Customer Service or visiting hap.org Give a copy of your DPAHC to your representative and your doctor For more information about advance directives or to download a form, visit Making Sure Everyone Gets Care It s our mission to enhance the health and well-being of the lives we touch. This means making sure you get great care. To that end, we offer health fairs and other community outreach programs to promote health, wellness and service. You can help us meet member needs by letting us know about you. We, and your doctors, may ask you questions about your race and ethnicity. We may ask what languages you speak. Getting this information is the first step in making sure we have the programs in place to meet all of our members needs. Giving us this information is voluntary. Any information you provide is, of course, confidential. It isn t used to decide your coverage or cost-sharing or claims amounts. It isn t used to discriminate against you in any way. We appreciate you helping us improve and expand our services. When we work together, we can help improve the quality of life for our entire membership. 27

30 Member Rights and Responsibilities As a member, you have the right to: Get complete information about your health plan. This means our services, practitioners and providers and your rights and responsibilities Get private, thoughtful and respectful care. Care does not take nationality, race, creed, color, age, economic rank, sex or lifestyle into consideration Work with your doctors in making choices about your health care. Talk to your doctor to fully understand your illness or treatment Have a candid talk with your providers about your treatment alternatives, no matter the cost or benefit coverage Be provided with all the information you need to give informed, legally needed consent before the start of any procedure or treatment. This includes an explanation of procedures and any risks Voice a complaint about us or appeal our services Make recommendations about our members rights and responsibilities policies Be told about affiliated providers available for medical care Expect us to make a reasonable answer to your requests Get prompt care in an emergency As a member, you have the responsibility to: Make your medical history and symptoms known before and during the course of treatment Tell us of any changes in important membership information Tell your doctor of any unexpected changes in your health Follow the plans and directions for care that you agreed on with your providers Understand your health problems Take part in creating mutually agreed-upon treatment goals, to the degree possible Cooperate in full with your providers Understand our procedures and use the plan in the right way Respect the rights of other patients and members 28

31 Common Terms Administrative Services Only A benefits plan structure in which the employer funds the plan and assumes financial responsibility for all of the claims and liabilities made against it. The employer typically hires a third party to administer the plan and process claims and payments. Affiliated Provider A doctor contracted with us to provide health care. Allowable Amount The maximum amount on which a payment is based for covered health care services. This may be called eligible expense, payment allowance or negotiated rate. If your provider charges more than the allowable amount, you may have to pay the difference. Appeal A request for us to review and/or reconsider a decision or grievance. Balance Billing When a doctor bills you for the difference between the doctor s charge and the allowable amount. For example, if the doctor s charge is $100 and the allowable amount is $70, the doctor may bill you for the remaining $30. A plan-affiliated doctor may not balance-bill you. Benefits The services a health plan covers, such as doctor office visits, routine physicals, etc. Brand-Name Drug A drug protected by a patent with a trade name from the original manufacturer. The manufacturer keeps the rights to sell the drug for a set period of time. After that time is up, the formula must be released, and other manufacturers can make a generic form of the drug. Coinsurance The percentage of charges for certain covered services that you pay after your deductible has been met. For example, if your plan specifies a 20 percent coinsurance for an allowable $100 office visit, and you ve met your deductible, your coinsurance payment would be $20. The health plan pays the rest of the allowed amount. (Note: Coinsurance can vary by plan, and some plans don t have it at all.) Copay A set amount you pay each time for a covered service, the purchase of prescriptions or other medical supplies. The copay amount can vary by the type of covered health care service. Cost-Sharing Set arrangements where you pay for designated portions of your covered care. This may be through copays, coinsurance and deductibles and/or through payroll deductions funding a part of the premium costs. Covered Services Medically necessary health care services and benefits that have been preauthorized by an affiliated provider according to your health plan s accepted policies. Deductible The amount you owe for certain covered services before your health plan begins to pay for them. There are per-person (individual) deductible amounts and family deductible amounts. For example, if your deductible is $1,000, your plan won t pay anything until you ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Dependent A person who receives health coverage through a spouse, parent or other family member who is the contract or policy holder. 29

32 Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches or blood testing strips for people with diabetes. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Excluded Services Health care services that your plan doesn t pay for or cover. Generic Drug A drug that has the same active ingredients as the original brand-name drug. It might use different inactive ingredients, like fillers that may affect the color or shape of the drug. In other respects, the drug is clinically identical. Generic drugs usually cost 30 percent to 60 percent less than brand-name drugs. They are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. Grievance A complaint that you communicate to your plan. Health Maintenance Organization (HMO) A form of health coverage that emphasizes preventive care. With an HMO, members prepay a premium for health care services, which generally include inpatient and outpatient care. For the member, it means reduced out-of-pocket costs and no paperwork. Hold Harmless Prevents you from being billed for charges for covered services from an affiliated provider due to events beyond your control. Hospital Outpatient Care Care in a hospital that usually doesn t need an overnight stay. Hospitalization Care in a hospital that requires admission as an inpatient and usually needs an overnight stay. An overnight stay for observation could be outpatient care. Independent Review Organization An outside medical review organization hired by health care providers and facilities to provide objective, unbiased medical opinions that support effective decision-making based on medical evidence. Medical Center A place with many doctors under one roof. This can mean PCPs and specialists. It can also mean services, like lab, X-ray and optical. Medically Necessary Health care services or supplies that are needed to prevent, diagnose or treat an illness, injury, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers that your health plan has contracted with to provide health care services. Non-Affiliated Provider A medical partnership or individual doctor who does not have a contract with your health plan. Except for PPO plans, services received from non-affiliated providers are not covered, unless the care received is considered an emergency. 30

33 Out-of-Pocket Limit The most you will pay for the combined total of all copays, coinsurance and deductibles for covered services in a benefit period (usually a calendar year). Once you meet your out-of-pocket limit, your health plan pays all of the allowed amount for covered services. Personal Care Physician (PCP) A doctor who directly provides or coordinates a range of health care services for you. Plan Sponsor An employer that sets up a health care plan for the benefit of its employees. The responsibilities of the plan sponsor include determining the plan design and funding covered claims. Preauthorization A decision by your health plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. It is sometimes called prior authorization, prior approval or precertification. Your plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization is not a promise that your plan will cover the cost. Preferred Provider Organization A PPO is a type of health plan that gives you the most flexibility, in most cases, but often has higher monthly premiums and out-of-pocket costs, like deductibles and coinsurance, than other plans. Like HMOs, a PPO uses a select group of doctors, specialists and hospitals, called a provider network. With a PPO, you don t need to select a PCP, and you won t need a referral to see a specialist. You can get care from doctors, hospitals and specialists in network or out of network. But keep in mind, you ll pay more for out-of-network services. Premium The amount that must be paid for your plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage A plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Preventive Care Health care that stresses finding out early about problems and providing early care of conditions, including routine doctor s exams, vaccines and well-person care. Prior Authorization This action ensures that certain medications or medical services are used correctly and only when truly necessary. Some plans may use a system where doctors or members need to get approval from the plan before a medication or service is covered. Provider A doctor, health care professional or health care facility licensed, certified or accredited as required by state law. Referral Preapproval from a PCP for specialty care. Referrals are usually paperless and must follow your health plan s guidelines. Self-Funded HMO Health plan coverage that is designed to look and feel like a health maintenance organization (HMO), but the coverage received for medical, drugs and other services is paid for by the plan sponsor instead of through an insurance contract. 31

34 Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A nonspecialist is a provider who has more training in a specific area of health care. Step Therapy A type of prior authorization for some prescription medications. With step therapy, in most cases, members must first try using certain less expensive medications that have been proven effective for most people with the same condition. Third-Party Administrator (TPA) An organization that processes insurance claims or certain aspects of employee benefit plans for a company. This can be viewed as outsourcing the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or a similar medical service. The UCR amount sometimes is used to determine the allowable amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to need emergency care. Alliance Health and Life Insurance Company is a wholly owned subsidiary of Health Alliance Plan (HAP). An ASO plan is administered by Alliance Health and Life Insurance Company. HAP Personal Alliance HMO is offered through Health Alliance Plan (HAP), a state-certified Health Maintenance Organization. HAP Personal Alliance PPO is offered through Alliance Health and Life Insurance Company (Alliance), a wholly owned subsidiary of Health Alliance Plan (HAP). 32

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