Blue Cross Complete Member Handbook

Transcription

2016
Includes:
Preferred Drug List and
Specialty Drug Guide
Guidelines to Good Health
Certificate of Coverage
Member Handbook
A guide for all Blue Cross Complete members
Contact us
Welcome to Blue Cross Complete
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: 1-800-228-8554 (TTY users should call 1-888-987-5832.)
24 hours a day, seven days a week
Pharmacy Customer Service
Call toll free: 1-888-288-3231 (TTY users should call 1-888-988-0071.)
8:30 a.m. to 6 p.m. Monday through Friday
Write to us: Blue Cross Complete
Suite 210
100 Galleria Officentre
Southfield, MI 48034
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.
Getting started
• Choose a doctor to be your primary care physician. You must have a primary care doctor
to use your benefits.
Other important phone numbers
24-hour Nurse Help Line
1-888-288-1724 (TTY: 1-888-987-5832)
– 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.
Anti-fraud Unit
1-855-232-7640 (TTY: 711)
Bright Start® maternity program
1-888-288-1722 (TTY: 1-888-987-5832)
Outreach Team
1-888-288-1722 (TTY: 1-888-987-5832)
(health education and resources)
1-800-784-8669 (TTY: 1-888-261-6259)
Transportation1-888-803-4947 (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.
• 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 the doctor for this appointment within 150 days, or at about five months. During this
visit, you’ll complete a Health Risk Assessment form.
If you have any questions, please contact us. We look forward to serving you.
Special needs
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.
Special needs Please call Customer Service if you need free help in another language or
Necesidades especiales
format.alIf Cliente
you’d like
to speakayuda
in another
language,
need help
reading
or en otro idioma,
Por favor, llame a Servicio
si necesita
en otro
idioma oorformato.
Si desea
hablar
understanding a document, we can help. We can even help you in another
o necesita ayuda para leer o entender un documento, le podemos ayudar. Incluso le podemos ayudar en otro
language when you’re at your doctor’s office. Written materials may be available
idioma cuando está en el consultorio de su médico. Los materiales impresos pueden estar disponibles en otros
in other formats.
formatos.
‫ﺍاﻻﺣﺘﻴﯿﺎﺟﺎﺕت ﺍاﻟﺨﺎﺻﺔ‬
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.
• Certificate of Coverage: This is your health care contract with us.
Visit us online: MiBlueCrossComplete.com
Tobacco quit program
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.
‫ ﺃأﻭو ﺗﺤﺘﺎﺝج‬،٬‫ ﺇإﺫذﺍا ﻛﻨﺖ ﺗﺮﻳﯾﺪ ﺍاﻟﺘﺤﺪﺙث ﺑﻠﻐﺔ ﺃأﺧﺮﻯى‬.‫ﺍاﻟﺮﺟﺎء ﺍاﻻﺗﺼﺎﻝل ﺑﺨﺪﻣﺔ ﺍاﻟﻌﻤﻼء ﺇإﺫذﺍا ﻛﻨﺖ ﺗﺤﺘﺎﺝج ﻣﺴﺎﻋﺪﺓة ﻣﺠﺎﻧﻴﯿﺔ ﺑﻠﻐﺔ ﺃأﺧﺮﻯى ﺃأﻭو ﺷﻜﻞ ﺁآﺧﺮ‬
‫ ﻳﯾﻤﻜﻦ ﺗﻮﻓﺮ ﺍاﻟﻤﻮﺍاﺩد ﺍاﻟﻤﻜﺘﻮﺑﺔ‬.‫ ﻳﯾﻤﻜﻨﻨﺎ ﺃأﻳﯾﻀﺎ ً ﻣﺴﺎﻋﺪﺗﻚ ﺑﻠﻐﺔ ﺃأﺧﺮﻯى ﻋﻨﺪﻣﺎ ﺗﻜﻮﻥن ﻓﻲ ﻣﻜﺘﺐ ﻁطﺒﻴﯿﺒﻚ‬.‫ ﻳﯾﻤﻜﻨﻨﺎ ﺍاﻟﻤﺴﺎﻋﺪﺓة‬،٬‫ﻣﺴﺎﻋﺪﺓة ﻟﻘﺮﺍاءﺓة ﺃأﻭو ﻓﻬﮭﻢ ﻭوﺛﻴﯿﻘﺔ‬
.‫ﺑﺄﺷﻜﺎﻝل ﺃأﺧﺮﻯى‬
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
Table of contents
Part 1: Your Blue Cross Complete
health plan......................................... 3
Part 1: Your Blue Cross Complete health plan
Part 6: MIChild................................. 45
Information for members enrolled through the
state’s MIChild plan.
How to choose a doctor, make an appointment
and get care.
Getting primary and speciality care.................... 4
Part 7: Update your personal
records............................................. 46
After hours, hospital and follow-up care............ 5
What to do when your family size changes and
how to tell us your wishes for medical care, such
as life support.
Appointments..................................................... 9
Copays and reimbursements............................ 11
If your family changes....................................... 46
Part 2: Your health care benefits...... 13
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
1
Enrollee Name:
Your name
2
Enrollee ID:
Identifies your
record in our files
Make your wishes known.................................. 46
What’s covered by Blue Cross Complete and the
state of Michigan.
Part 8: Your rights and
responsibilities................................. 48
What’s covered by Blue Cross Complete......... 13
What’s covered by the state of Michigan......... 21
To get the most from your health care, follow
these rights and responsibilities.
Part 3: Prescription benefits............ 25
Beneficiary ID:
Number assigned
to you by the state
3
Member rights.................................................. 48
Read about your drug benefits, including
generic medicines, filling a prescription,
finding a pharmacy and the medicines we cover.
Member responsibilities................................... 49
Help identify health care fraud......................... 50
Medicines covered by Blue Cross Complete... 25
Part 9: If you have a concern........... 52
Medicines covered by the state of Michigan.... 26
What to do if you have a complaint or would like
to appeal a medical decision.
Preferred Drug List........................................... 27
Specialty Drug Guide....................................... 29
Part 10: Your privacy........................ 55
Learn more about preventive health care,
including recommended tests and screenings,
healthy behaviors and important health numbers
you should always know.
How we handle your private and confidential
Enrollee Name
information.
VALUED CUSTOMER
6
Rx: Shows you have drug coverage
MiBlueC ros s C omplete.com
Your card may look
slightly different.
Plan
RxBIN
Issuer (80840)
Notice of Privacy Practices...............................
56
Michigan Beneficiary ID
M12345678
Part 11: Our Board of Managers...... 62
Part 5: Healthy Michigan Plan.......... 38
The Blue Cross Complete Board of Managers
helps adopt and put in place the policies that
say how Blue Cross Complete runs.
Additional information for Blue Cross Complete
members enrolled through the state of Michigan’s
Healthy Michigan Plan.
Certificate of Coverage.................... 63
What the Healthy Michigan Plan covers........... 39
How the Healthy Michigan Plan works............. 40
6
RxBIN & RxPCN: Drug plan numbers
XYU888888888
Guidelines to Good Health.............................. 36
4
3
5
Our commitment to your privacy..................... 55
9101000021
5
Group Number:
Shows the group in which you’re enrolled
Enrollee ID
Health information to support your goals........ 30
2
4
Grievances and appeals................................... 52
Part 4: Guidelines to good health.... 30
1
RxPCN
Group Number
00277723
HMO
600428
06210000
Blue Cross Complete of Michigan LLC Customer Service
An in depen den t licen see of t h e Blu e Cross an d
Blu e Sh ield Associat ion
Hospital and medical claims – Providers in
Michigan, file claims with:
Blue Cross Complete
P.O. Box 7355
London, KY 40742
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 19029
PerformRx
Blue Cross Complete: 800-228-8554
TTY/TDD:
PerformRx:
TTY/TDD:
888-987-5832
888-288-3231
888-988-0071
Mental health/substance
abuse treatment:
888-288-1722
Providers Only:
Medical authorizations
and inquiries:
888-312-5713
Pharmacy authorizations
and inquiries:
888-989-0057
Misuse may result in prosecution.
If you suspect fraud:
855-232-7640
Use of this card is subject to terms of
applicable contracts and certificates.
Pha rma c y Be ne f it s Adminis t ra t or
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:
Supplemental Certificate of Coverage for
Healthy Michigan Plan members...................... 43
• A magnetic strip to help providers process claims in the future. It has
information from the front of the card and your birth date. It doesn’t
have any benefit or health information.
• Toll-free Customer Service numbers and other important numbers.
2
3
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Getting primary and specialty care
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.
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.
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.
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.
State and federal health centers
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.
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, call Customer
Service.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
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.
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.
After hours, hospital and follow-up care
Obstetrics and gynecology
If you need nonemergency care outside of normal business hours, call your
doctor first.
Women: You may get routine obstetrics and gynecology care from your
primary care doctor. You may also get other women’s health specialist
services from any network provider. You don’t need a referral.
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.
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.
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.
Learn more about healthy
pregnancies in Part 4:
Guidelines to good health.
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.
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.
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.
4
5
1-888-288-1724
24 hours a day,
seven days a week
Hospital care — Emergencies and nonemergencies
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.
Emergency care
You are covered anywhere in the world for emergency services. You don’t
need a referral or prior authorization to get emergency care.
!
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.
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
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.
In an emergency, don’t delay — go to the nearest emergency
room or call 911.
• Any organ or part of your body may not work properly again.
Minor sore throat
Emergency conditions may include:
Nonemergency
• Severe pain
Call your doctor or go
to an urgent care
center for:
• Unusual chest pain
• Problems breathing
Earache
Minor cuts and scrapes
Sprains and strains
Fever under 103º F
Colds and flu
• Puncture wounds
Broken bones or severe sprains
• Nonstop bleeding
Deep cuts or uncontrolled bleeding
• Broken bones
Poisoning
• Severe bites or burns
Severe burns
• Blows to the head
Chest pain or sudden severe pain
• Sudden loss of strength or feeling in the arms or legs
Emergency
Go to the ER or call
911 for:
Emergency services are:
• Given by a provider who is qualified
• Needed to evaluate or stabilize an emergency
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
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.”
Seizures
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 emergency transportation.
Sudden blurred vision or sudden severe or
unusual headache
!
1-888-288-1724
24 hours a day,
seven days a week
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.
Difficulty breathing
Learn more about
transportation in Part 2: Your
health care benefits.
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.
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.
6
7
Did
you
know?
You can see a network OB-GYN
without a referral.
Choosing a doctor
Out-of-network services
Out-of-network service means care provided by doctors who aren’t in our
network. When you are outside of the service area, including out of the state
or out of the country, Blue Cross Complete does not pay for routine care.
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.
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. We’ll cover them until a network doctor can provide them.
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.
Prior authorization
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.
Visit us online:
MiBlueCrossComplete.com
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.
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.
If you’re traveling, we may cover medically necessary services with prior
authorization.
Appointments
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.
To see your doctor, you’ll need an appointment.
Making an appointment
Changing your primary care doctor
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 need to change your doctor, please call Customer Service. They can
explain how it works and help you find a new doctor in our network. If you
need health care before your change is effective, see your current doctor.
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 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.
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.
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.
Sometimes, Blue Cross Complete needs to give permission for you to get
some services. This is called prior authorization. Call Customer Service to
make sure you have the authorization you need.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
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 1-888-803-4947 from 8 a.m. to 5:30 p.m. Monday
through Friday.
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.
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.
8
9
Learn more about
transportation in Part 2: Your
health care benefits.
Copays and reimbursements
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.
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.
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
For
Standard
scheduling
times
Preventive
care (primary
and specialty
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.
30 calendar
days
Routine care
10 calendar
Conditions that are not sudden or not life
threatening, or symptoms that keep coming days
back, such as rashes and joint or muscle
pain. Or, conditions that need ongoing care.
Urgent 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.
Within 48
hours
A condition that is life threatening or
requires immediate help.
Right away
Emergency
care
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.
Learn more about urgent and
emergency care in After hours
and follow-up care in this
section.
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 or country. 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.
Type of visit
For
Standard
scheduling
times
Travel costs: To ask us to reimburse approved travel costs, including meals
and lodging, for medical care, 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.
Routine care
Cases where no danger is found and your
ability to cope is not in danger.
Within 10
business
days
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.
Urgent care
Conditions that are not life threatening, but
face-to-face contact is needed quickly, such
as anxiety or panic attacks.
Within 48
hours
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.
Emergency
care (not life
threatening)
Within 6
Conditions that require rapid help to
prevent a decline in your state of mind that, hours
if left untreated, could put your safety at risk.
Emergency
care (life
threatening)
Conditions that require immediate help to
prevent death or serious harm to
yourself or others.
Mental health services
10
Right away
Please send your form and information within either:
• 90 days of when you receive the bill or
Did
you
know?
Your child can see a network
pediatrician without a referral.
• 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.
11
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Part 2: Your health
care benefits
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.
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.
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
What’s covered by Blue Cross Complete
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 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:
• 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.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
• We do not pay care management staff to make decisions to give you
less care than you need.
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.
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:
Outreach Team
1-888-288-1722
8 a.m. to 6:30 p.m.
Monday through Friday
• Clinical practice guidelines
• Quality Improvement program, which includes our goals and progress
For disease and health information, call our Outreach Team.
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
• Regular or annual well visits
•Vaccines
• Lab work, X-rays and other imaging services
• Allergy testing, treatment and injections
• Family planning, including birth control
12
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.
Quality improvement programs
•CAHPS scores
• Urgent and emergency care
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.
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.
®
• Medical supplies, such as diabetes test strips
Learn more about your drug
coverage for prescriptions in
Part 3: Prescription benefits.
•Medicines
• 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.
•HEDIS® scores
• Health care such as doctor’s visits, vaccines and more
13
Learn more about all your
benefits in the Certificate of
Coverage at the back of this
book.
Durable medical equipment
• HIV/AIDS testing and treatment of sexually transmitted diseases
Some medical conditions need special equipment. Durable medical
equipment we cover includes:
• Services you may get at Federally Qualified Health Centers
• Health education programs, including chronic condition management
and tobacco cessation
• Equipment such as nebulizers, catheters, crutches, wheelchairs and
other devices
• Nutritional counseling for members with certain conditions, such as
heart failure, diabetes or prediabetes, high body mass index and more
• Disposable medical supplies, such as ostomy supplies, peak flow meters
and alcohol pads
• Medically necessary weight reduction services
• Diabetes supplies, such as lancets, test strips, insulin needles, blood
glucose meters and insulin pumps
• Emergency and urgent care services
• Prosthetics and orthotics
• Rehabilitative therapy, including cardiac rehab, physical, speech and
occupational therapies
– 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.
Hospital and surgical care
When you need extra care or have an emergency, we cover most hospital
care, surgery and lab work. This includes:
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.
• Outpatient surgical services (this is when you don’t stay overnight at a
hospital)
• Chemotherapy and other drug treatments for cancer
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
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:
• Dialysis and treatment of kidney disease, including end-stage renal
disease
• Cost of a shared hospital room
• Routine eye exams
• Intensive care nursing
• A pair of glasses
• Lab work, X-rays, imaging services, therapies and other medical
supplies while you’re in the hospital
• 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.
• Surgeries, including organ transplants
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.
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:
Hearing: How well you hear affects your quality of life. We help you hear the
best you can by covering:
• Short-term nursing home services (long-term care is provided by the
state of Michigan)
• Hearing exams for all members
• Home health care services for members who are homebound
• Hearing aids for members under age 21 and Healthy Michigan Plan
members
• Supplies and equipment related to home health care
Healthy Michigan Plan members: Learn more about your hearing aid
benefits in Part 5: Healthy Michigan Plan.
• 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.
To find a network hearing provider, call Customer Service or use our online
provider search.
Did
you
know?
Talk to a nurse anytime. We
have a free 24-hour Nurse
Help Line.
14
15
Visit us online:
Care for women
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 covered by
the state of Michigan in this section. Blue Cross Complete may cover oral
surgery in some situations.
Healthy Michigan Plan members: Learn more about your dental
Mental health services
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
Learn more in What’s covered
by the state of Michigan.
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.
• Prenatal and postpartum care
• Midwife services
• Delivery care
• Parenting and birthing classes
• Mammograms and breast cancer services, such as treatment and
reconstruction
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.
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.
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
• Durable medical equipment suppliers to pick up your medical supplies
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.
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:
Transportation
1-888-803-4947
8 a.m. to 5:30 p.m.
Monday through Friday.
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
• Transfers between hospitals
• Early Periodic Screening Diagnosis and Treatment program services
• Ambulance transportation between a skilled nursing facility and hospital
• Hearing exams and hearing aids
• Eye exams and glasses
• Oral health screening and fluoride treatment
16
1-888-288-1724
24 hours a day,
seven days a week
• Pap tests
Transportation
• Pharmacies to pick up your prescriptions
• HIV/AIDS testing and treatment of sexually transmitted diseases
• Pregnancy and maternity care
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.
!
• Birth control and birth control counseling
17
Outreach Team
1-888-288-1722
8 a.m. to 5:30 p.m.
Extra help and health programs
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 1-800-359-3722 from 8 a.m. to 5 p.m. Monday through Friday.
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.
Outreach Team
1-888-288-1722
8 a.m. to 5:30 p.m.
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.
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 1-517-241-7420.
Customer Service can answer your questions about EPSDT and CSHCS.
Chronic condition management
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:
1-888-288-1724
24 hours a day,
seven days a week
If you have a chronic medical condition such as diabetes or heart disease,
we’ll enroll you in our free chronic condition 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.
Care management
If you are seriously ill or injured, we can give you the extra help and support
you need through 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.
• Physical and developmental exams, including autism screening
• Height and weight
• Blood pressure test
Your personal care management is handled by 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.
• Hearing, vision and dental tests
• Vaccines
• Lead screening
Your nurse works with you and your doctor 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.
• Cholesterol screening, as needed
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.
Bright Start® pregnancy program
Our Bright Start® program is especially for our pregnant members. We want
to make sure you have all you need for a healthy pregnancy and baby.
Children’s Special Health Care Services Program
Bright Start will help you learn about pregnancy and prepare for delivery.
Members who are in the program can also reach out to or work with a case
manager when they have questions.
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.
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.
18
Did
you
know?
Get where you’re going. Our
free ride service can help you
get to your covered services.
Call our Outreach Team if you’d like to find
out more about our chronic condition and case
management programs or Bright Start.
19
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Tobacco cessation
Using the right health services in the right amount helps make sure you are
getting the very best care.
If you use tobacco, we can help you whether you are thinking about quitting,
are ready to quit or just want more information. We have several options to
help you quit using tobacco. You and your provider can decide what
therapies or combination or therapies are best for you.
Excluded medical and drug services
Some services and drugs aren’t covered. For a complete list, please see your
Certificate of Coverage. These services are not covered:
• Elective abortion and related services
Our tobacco quit program is a free, phone-based support program that
gives you support and resources to increase your success of quitting. You’ll
talk to a nurse health coach, who can help you create a plan to quit and set a
date to start a new life without tobacco.
This program can offer personal support and encouragement, answer
questions and track your progress. Each phone session is designed to help
you overcome the urge to use tobacco.
• Infertility treatment
1-800-784-8669
8 a.m. to 1 a.m.
seven days a week
Your doctor may suggest medical services that Blue Cross Complete doesn’t
cover. If you get services Blue Cross Complete doesn’t cover, you may have
to pay for them. Sometimes, the Michigan Department of Health and Human
Services or another agency may cover them.
See your Certificate of Coverage or call Customer Service to check your
coverage before getting medical services. Learn about what the state covers
in What’s covered by the state of Michigan in this section.
Group and individual counseling and coaching
We also cover group and individual counseling or coaching to help you quit
smoking. These sessions are in addition to your 20 outpatient mental health
visits.
New technology
Experts advise Blue Cross Complete on changes in medical practice and
technology. This helps Blue Cross Complete decide which new services to
cover. This is how Blue Cross Complete maintains benefits coverage. Please
see your Certificate of Coverage for more information.
Smoking cessation medicines
We cover many over-the-counter and prescription medicines that may help
you quit using tobacco.
Over-the-counter products may include generic forms of products such as
Nicorette® (gum), Nicoderm® (patch) and Commit® (lozenge). Prescription
medicines may include Nicotrol® (nasal spray, inhaler), generic Zyban® and
others.
Benefits monitoring program
We participate in MDHHS’ Benefits Monitoring Program. This program helps
you make the most of your benefits and use the services that are right for you.
We may review the services you need and use. Sometimes, you can use
health services better, or use different services, to manage your health. When
we see this opportunity, we teach you how to get these services and use
them.
To help you manage your health services, we may enroll you in this program.
We may do this if the services you use aren’t needed for your health
condition. This could include:
• Elective cosmetic surgery
Getting noncovered benefits
Together, you and your nurse health coach will create an action plan to
gradually stop using tobacco and set a quit date when you’re ready. For
more information or to enroll, call the tobacco quit program.
You may get any over-the-counter nicotine patches, inhalers, nasal sprays,
and gums or lozenges. You need a doctor’s prescription for the
over-the-counter medicines to be covered.
• Experimental or investigational drugs, procedures or equipment
Learn more about your
prescription benefits in
Part 3: Prescription benefits.
What’s covered by the state of Michigan
In addition to what Blue Cross Complete covers for you, the state of Michigan
covers some other services. To learn how to get these services, please call
your DHS case worker or Blue Cross Complete Customer Service.
Dental care
Any member under age 21 or his or her parent or guardian can call
Customer Service to find a dentist. For members age 21 and older, the
state of Michigan’s Medicaid program may cover routine exams, preventive
services and some other care. The state may also cover emergency services,
including treatment for pain or infection.
Healthy Michigan Plan members: Learn more about your dental
Developmental disabilities
The Michigan Community Mental Health Program helps people with
developmental disabilities. If you or anyone in your family may need these
services and is eligible for Medicaid, call Customer Service.
Did
you
know?
• Going to the emergency room when it’s not an emergency
• Seeing too many different doctors instead of your primary care doctor
Follow up with your doctor
within 24 hours after an urgent
care or emergency room visit.
• Getting more medicines than may be safe
• Or, activity that may indicate fraud
20
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
21
Drug and alcohol treatment
Maternal Infant Health Program
People who are dependent on drugs or alcohol may:
• Use drugs even if drugs have a poor impact on health, work or family
Some of the services include rides to your doctor’s office and classes about
childbirth and parenting. The program also helps you access other community
resources. The services are free and you don’t need a referral. For
information or to find an MIHP provider, please call Customer Service.
• Be violent sometimes
Transportation
You may wonder if you or someone in your family has a problem with drugs
or alcohol. Drug and alcohol abuse have some classic signs, according to the
National Institutes of Health.
The Maternal Infant Health Program may be able to help you during your
pregnancy. MIHP can help you get services from providers, such as a social
worker, nurse, nutritionist or other health care provider.
• Seem confused
These state programs may provide transportation service. If you live in
Wayne County and need a ride for dental, substance abuse and some
mental health services, call Logisticare. They can be reached at
1-866-569-1902 from 8 a.m. to 5 p.m. Monday through Friday.
• Be upset when asked about drug use
• Be unable to stop or reduce use
• Make excuses to use drugs
Additional services
• Miss work or school, or start doing poorly at work or school
These services are not covered by Blue Cross Complete but may be
available to you:
• Need to use drugs or drink regularly, such as every day, to feel normal
• Not eat or take care of their appearance
• Services provided by a school district
• Take part in less activities
• Long-term mental health services such as psychiatric services and
outpatient partial hospitalization
• Try to hide drug use
• Substance abuse services, such as screening and assessment,
detoxification, intensive outpatient counseling, methadone treatment
• Use drugs when they’re alone
• Long-term care in the home through home and community-based
program services
Who to call for treatment
To get help for drug or alcohol issues, please call your local substance abuse
coordinating agency. You can also call Customer Service.
• Custodial care in a nursing facility
Nursing home services
• Personal care and home help services
Blue Cross Complete pays for short-term nursing home services. Medicaid
pays for long-term nursing home services. For more information, call
Customer Service.
• Traumatic brain injury program services
For more information on how to access these services, call your DHS case
worker or Blue Cross Complete Customer Service. There may be small
copays for services provided by the state of Michigan.
Women, Infants and Children program
WIC is a program that provides healthy foods and education about eating
right. WIC is for:
• Pregnant women
• Women who have just had a baby and are breast feeding
• Children up to age 5
Call your county health department for information on how to get services
through WIC, or talk to your DHS case worker.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Did
you
know?
If you can’t keep your
appointment, try to reschedule
24 hours in advance.
22
23
An overview of your Blue Cross Complete
coverage and benefits
Here is an overview of your benefits. Your benefits include, but are not
limited to, these. Always refer to your Certificate of Coverage for the most
detailed information.
Blood lead testing for members under
age 21
Out-of-network and out-of-state services
– when authorized by Blue Cross Complete
Breast cancer services – services to treat
breast cancer as required by federal
and state women’s health and cancer
protection acts, including diagnostic,
outpatient treatment and rehabilitative
services
Parenting and birthing classes
Child and Adolescent Health Centers
Practitioner services – such as those
provided by physicians and specialists
Chiropractic services
Diagnostic laboratory, X-ray and other
imaging services
Doctor office visits
Emergent and urgent care services
Family planning services
Federally Qualified Health Centers
Health education – disease management
programs
Hearing exams for all members and
hearing aids for members under age 21
Physical exams – routine or annual
physical exams
Podiatric (foot specialist) services when
medically necessary
Pregnancy care – including prenatal and
postpartum care (before and after birth)
Prescriptions and pharmacy services
Prosthetics and orthotics
Rehabilitative or restorative services –
intermittent or short term, in a nursing
facility for up to 45 days
Rehabilitative or restorative services in
a place of service other than a nursing
facility
Renal disease services – end stage
Home health services and skilled nursing
home services, when medically
necessary (You can use these after you
leave the hospital or instead of going to
the hospital. Your doctor will help you
arrange these services.)
Sexually transmitted disease treatment
Hospice services (if you request)
Surgical services – not requiring an
overnight hospital stay
Hospital services requiring an overnight
stay, including:
– Cost of a semi-private room (sharing
a room with one other person)
– Intensive care nursing services
– Doctor services
– Surgical services
– Anesthesia (medication to relax or
put you to sleep before surgery)
–X-rays
– Laboratory services
Medical equipment and supplies,
durable
Smoking and tobacco cessation treatment,
including drugs and behavioral support
(tobacco quit program)
Specialist visits
Therapy – physical, speech and
language, occupational
Transplant services
Transportation – by ambulance and other
emergency medical transport
Transportation – to nonemergency
covered medical services
Vaccinations (Covered vaccinations do
not require prior authorization if
provided by local health departments.)
Vision – routine services
Mental health services – short term, up
to 20 outpatient visits per year
Weight-reduction services – if medically
necessary
Midwife services – when provided by a
certified nurse midwife
Well-baby and well-child care – Early
Periodic Screening Diagnosis and
Treatment Program for persons under
age 21
Nurse practitioner services – when provided
by a certified pediatric or family nurse
Part 3: Prescription
benefits
Medicines covered by Blue Cross Complete
Your drug benefit covers most generic medicines. Your benefit also covers
some over-the-counter medicines when you have a prescription. These
include pain relievers, laxatives, iron tablets, family planning drugs or
supplies, and others.
Our online drug search includes all the medicines we cover. The drug search
lists our guidelines for these drugs, such as any quantity limits, if prior
authorization is needed, if the medicine is a generic or brand drug, and more.
If you have questions about your pharmacy benefit or if you don’t have
Internet access, contact Pharmacy Customer Service. You can ask us for
copies of this information.
Brand name and generic drugs
Your pharmacy will fill your prescriptions with the generic version when one
is available. In the U.S., 70 percent of all prescriptions are filled with generic
medicines, according to Generic Drugs, a 2010 U.S. Food and Drug
Administration presentation.
Generic drugs are nearly the same as brand-name drugs. They’re approved
by the FDA. To be approved, they must have the same active ingredient,
strength and form, and act the same in your body as the brand medicine.
Generic medicines have to be made to the same strict standards as the
brand medicine.
They may have a different color and shape, but these are the only differences.
You might notice that some generics of the same drug also look different
from each other. This is because they may be made by different companies.
But the ingredients are still the same. Generics also are much less expensive.
If your doctor feels the brand-name version is medically necessary and can’t
be substituted with the generic version, he or she must ask Blue Cross
Complete to authorize the brand-name version.
Filling a prescription
We may cover up to a 34-day supply of most medicines. If you have
questions, call Pharmacy Customer Service.
At a retail pharmacy: You may fill most prescriptions at any pharmacy in our
network.
Our network includes both many independently owned pharmacies, as well
as chain stores.
To find a network pharmacy, you can call Pharmacy Customer Service or use
the Find a Blue Cross Complete pharmacy search on our website.
If you have questions about your Blue Cross Complete benefits, please call
Customer Service.
24
Visit us online:
25
Pharmacy Customer Service
1-888-288-3231
8:30 a.m. to 6 p.m.
For specialty drugs: Specialty drugs are medicines for complex or rare
conditions, such as rheumatoid arthritis, multiple sclerosis and others. You
may fill these prescriptions by mail.
Preferred Drug List (Effective April 2015)
If you need information about or help getting your specialty drugs, call
Pharmacy Customer Service. They will help connect you with the specialty
pharmacy.
Antihistamines and
Decongestants
Prior authorization
Your doctor will work with Blue Cross Complete to make sure you’re covered.
Sometimes your doctor may need to ask us to cover a medicine before it’s
prescribed. When your doctor does this, he or she asks Blue Cross Complete
for prior authorization.
Members must sometimes meet certain conditions, try other medicines, have
certain medical conditions or be a certain age before we can cover some
medicines. Sometimes, these requirements are set by the state of Michigan.
Another reason your doctor may ask for prior authorization is if he or she
would like to prescribe a medicine for a reason other than the drug’s original
purpose.
If a drug isn’t covered
If a drug is not on the Preferred Drug List or Specialty Drug Guide, it may
not be covered by Blue Cross Complete. This might include drugs that are
specifically excluded from Michigan’s Medicaid program.
If your doctor would like to prescribe a medicine that isn’t covered, he or she
will ask Blue Cross Complete for prior authorization. You or your doctor can
ask Blue Cross Complete to add a medicine to our list of covered drugs. To
do this, write to us at:
Blue Cross Complete Pharmacy Management
Suite 210
100 Galleria Officentre
Southfield, MI 48034
Blue Cross Complete will review the drug and determine if it will be added
to the list of covered drugs.
Learn more about medicines that may not be covered in Part 2: Your health
care benefits and your Certificate of Coverage. If you have any questions
about prescriptions or your prescription benefit, call Pharmacy Customer
Service.
Medicines covered by the state of Michigan
Some medicines are covered by the state of Michigan instead of by Blue
Cross Complete. This includes drugs used for HIV or AIDS, seizure disorders,
sleep problems and some types of mental illness.
See the state’s list at michigan.fhsc.com/Providers/DrugInfo.asp. This list is
also available on our website. The state may charge a small copay for these
medicines.
Learn more about which
medicines Blue Cross Complete
covers in the Preferred Drug List
and the Specialty Drug Guide in
this section.
Preferred
Azelastine - Astelin Nasal Spray (g)
Cetirizine - Zyrtec (OTC) (g)
Cyproheptadine - Periactin (g)
Diphenhydramine - Benadryl (g)
Fexophenadine - Allegra (OTC) (g)
Hydroxyzine - Atarax; Vistaril (g)
Loratadine - Claritin (OTC) (g)
P-ephed/Cetirizine - Zyrtec-D (OTC) (g)
P-ephed/Fexophenadine -Allegra D
(OTC) (g)
P‑ephed/Loratadine - Claritin‑D (OTC) (g)
Promethazine - Phenergan (g)
Anti‑Infectives
Preferred
Amox Tri/Potassium Clavulanate Augmentin, ES, XR (g)
Amoxicillin - Amoxil (g)
Azithromycin - Zithromax (g)
Cefaclor - Ceclor, CD (g)
Cefdinir - Omnicef (g)
Cefpodoxime - Vantin (g)
Cefprozil - Cefzil (g)
Cefuroxime - Ceftin (g)
Cephalexin Monohydrate - Keflex (g)
Ciprofloxacin - Cipro, XR (g)
Clarithromycin - Biaxin, XL (g)
Clindamycin - Cleocin (g)
Dicloxacillin (g)
Doxycycline Hyclate - Vibramycin (g)
Doxycycline Monohydrate - Monodox (g)
Erythromycin/Sulfisoxazole Pediazole (g)
Erythromycin (g)
Levaquin
Minocycline - Minocin; Dynacin (g)
Ofloxacin - Floxin (g)
Penicillin V (g)
Sulfamethoxazole/Trimethoprim Bactrim; Septra (g)
Tetracycline - Sumycin (g)
Prior Authorization Required
Avelox; Cedax; Erythromycin Filmtab;
Factive; Ketek; Maxaquin; Noroxin;
PCE; Proquin XR; Suprax; ZMax
Antivirals – Herpes
Preferred
Acyclovir - Zovirax (g)
Famciclovir - Famvir (g)
Valcyclovir - Valtrex (g)
Cardiovascular – ACE
Inhibitor
Preferred
Benazepril, HCTZ - Lotensin, HCT (g)
Captopril - Capoten (g)
Captopril/HCTZ - Capozide (g)
Enalapril - Vasotec (g)
Enalapril/HCTZ - Vaseretic (g)
Fosinopril - Monopril, HCT (g)
Lisinopril - Prinivil; Zestril (g)
Lisinopril/HCTZ - Prinzide;
Zestoretic (g)
Moexipril - Univasc (g)
Moexipril/HCTZ - Uniretic (g)
Quinapril, HCTZ - Accupril,
Accuretic (g)
Ramipril (capsules) - Altace (g)
Trandolapril - Mavik (g)
Cardiovascular – Angiotensin
Receptor Blocker
Preferred
Losartan - Cozaar (g)
Losartan/HCTZ - Hyzaar (g)
Step Therapy Required
Atacand, HCT; Avalide; Avapro; Azor
Benicar, HCT; Diovan, HCT; Exforge;
Micardis, HCT; Teveten, HCT
Cardiovascular – Beta
Blocker
Preferred
Acebutolol - Sectral (g)
Atenolol - Tenormin (g)
Atenolol/Chlorthalidone - Tenoretic (g)
Bisoprolol Fumarate - Zebeta (g)
Bisoprolol Fumarate/HCTZ - Ziac (g)
Carvedilol - Coreg (g)
Labetalol - Normodyne (g)
Metoprolol, HCTZ - Lopressor, HCT (g)
Metoprolol - Toprol XL (g)
Nadolol - Corgard (g)
Pindolol - Visken (g)
Propranolol - Inderal, LA (g)
Propranolol/HCTZ - Inderide (g)
Sotalol - Betapace, AF (g)
Timolol Maleate - Blocadren (g)
Cardiovascular –
Miscellaneous
Preferred
Amiodarone - Cordarone (g)
Cilostazol - Pletal (g)
Clonidine - Catapres (g)
Clopidogrel - Plavix (g)
Digoxin (g)
Dipyridamole - Persantine (g)
Enoxaparin - Lovenox (g)
Isosorbide Dinitrate - Isordil (g)
Isosorbide Mononitrate - Ismo;
Monoket; Imdur (g)
Nitroglycerin (g)
Pradaxa
Ticlopidine - Ticlid (g)
Warfarin Sodium - Coumadin (g)
Xarelto
Tekturna, HCT
Central Nervous System –
Miscellaneous
Preferred
Namenda
Razadyne, ER (g)
Cholesterol Lowering
Preferred
Atorvastatin - Lipitor (g)
Cholestyramine - Questran, Light (g)
Colestipol - Colestid (g)
Fenofibrate -Lofibra (g)
Fluvastatin - Lescol (g)
Gemfibrozil - Lopid (g)
Lovastatin - Mevacor (g)
Simvastatin - Zocor (g)
Advicor; Altoprev; Caduet; Crestor;
Lescol, XL; Simcor
Step Therapy Required
Vytorin
Diabetes
Preferred
Acarbose - Precose (g)
Cardiovascular – Calcium
Glimepiride - Amaryl (g)
Channel Blocker
Glipizide - Glucotrol, XL (g)
Preferred
Glipizide/Metformin - Metaglip (g)
Amlodipine - Norvasc (g)
Glyburide - Diabeta; Micronase (g)
Amlodipine/Benazepril - Lotrel (g)
Glyburide micronized - Glynase (g)
Diltiazem - Cardizem CD, SR; Dilacor
Glyburide/Metformin - Glucovance (g)
XR; Tiazac (g)
Humalog, Mix (vials, pen & cartridges)
Felodipine - Plendil (g)
Humulin, Mix (vials, pen & cartridges)
Isradipine - Dynacirc (g)
Lantus
Nifedipine - Adalat CC; Procardia, XL (g)
Metformin - Glucophage, XR (g)
Nicardipine - Cardene (g)
Novolin, Mix (vials, pen & cartridges)
Verapamil - Calan, SR;
Novolog, Mix (vials, pen & cartridges)
Isoptin, SR; Verelan, PM (g)
Supplies (strips, lancets, syringes)
Azor; Dynacirc CR; Lotrel 10/40, 5/40;
Actos; Avandia; Actoplus Met;
Tarka; Exforge
Avandamet; Avandaryl; Byetta; Duetact;
Glumetza; Glyset; Janumet, XR; Januvia;
Prandin; Starlix (g); Symlin, Victoza
(g) - Blue Cross Complete provides coverage for the generic equivalent
This list is current as of the date on the back of this handbook.
For our most updated list, visit us online at MiBlueCrossComplete.com.
26
27
Gastrointestinal Agents
Preferred
Cimetidine - Tagamet (g)
Famotidine - Pepcid (g)
Metoclopramide - Reglan (g)
Misoprostol - Cytotec (g)
Nexium OTC
Nizatidine - Axid (g)
Omeprazole - Prilosec (g); Prilosec OTC (g)
Pantoprazole - Protonix (g)
Prevacid OTC
Ranitidine - Zantac (g)
Sucralfate - Carafate tablets (g)
Aciphex; Prevacid (g); Zegerid (g)
Hormones – Contraceptive
Preferred
Desogestrel‑EE - Cyclessa, Desogen,
Ortho‑Cept (g)
Desogestrel EE - Mircette (g)
Estrostep FE (g)
Ethynodiol D‑EE - Demulen (g)
Levonorgestrel‑EE - Alesse, Levlite (g)
Levonorgestrel‑EE - Nordette; Levlen (g)
Levonorgestrel‑EE - Seasonale (g);
Seasonique (g); Loseasonique (g)
Levonorgestrel‑EE - Triphasil;
Tri-Levlen (g)
Medroxyprogesterone Acet Depo‑Provera (150mg) (g)
Noreth‑A‑EE/FE fumarate Loestrin, FE (g)
Norethindrone Acetate - Aygestin (g)
Norethindrone Ortho Micronor; Nor‑QD (g)
Norethindrone‑EE Modicon (g)
Norinyl, Ortho‑Novum (g)
Ovcon‑35 (g)
Tri‑Norinyl (g)
Norethindrone-EE/FE - Femcon FE (g)
Norgestimate‑EE - Ortho Cyclen (g)
Norgestimate‑EE - Ortho Tri-Cyclen (g)
Norgestrel‑EE - Lo/Ovral (g); Ovral (g)
Nuvaring
Ortho Evra
Drospirenone-EE - Yasmin (g); Yaz (g)
Amethia/LO; Beyaz; Camrese/LO;
Genress FE; Gianvi; Lo Loestrin;
Loestrin 24 FE; Loryna; Minastrin 24 FE;
Ortho Tri‑Cyclen Lo; Vestura; Zenchant
FE, Zeosa
Preferred Drug List (Effective April 2015)
Hormones – Miscellaneous
Preferred
Alora
Crinone
Depo‑SubQ Provera 104
Estraderm
Estradiol - Climara (g)
Estradiol - Estrace (g)
Estring
Estrogen, Ester/Me‑Testosterone Syntest, DS & HS (g)
Estropipate - Ogen; Ortho‑Est (g)
Medroxyprogesterone Acet - Provera (g)
Me‑testosterone/Estrogen, Ester Estratest, HS (g)
Premarin, Low Dose
Prempro, Low Dose
Prometrium
Migraine
Preferred
Imitrex injection, nasal spray, tablets (g)
Maxalt, MLT
Amerge (g); Axert; Frova; Relpax;
Zomig, ZMT, nasal spray
Miscellaneous
Natroba; Nudexta; Uloric
Muscle Relaxants
Preferred
Baclofen - Lioresal (g)
Chlorzoxazone - Parafon Forte (g)
Cyclobenzaprine - Flexeril (g)
Dantrolene - Dantrium (g)
Methocarbamol - Robaxin (g)
Orphenadrine Citrate - Norflex (g)
Orphenadrine/Aspirin/Caffeine Norgesic Forte (g)
Tizanidine - Zanaflex (g)
Skelaxin (g)
Ophthalmics – Anti‑Infectives
Preferred
Ciprofloxacin - Ciloxan (g)
Ofloxacin - Ocuflox (g)
Polymyxin B Sulfate (g)
Polymyxin B Sulfate/TMP - Polytrim (g)
Tobradex (g)
Tobramycin Sulfate - Tobrex (g)
Quixin (g); Vigamox; Zymar
Ophthalmics – Glaucoma
Preferred
Alphagan P (g)
Azopt
Brimonidine - Alphagan (g)
Cosopt (g)
Dipivefrin
Iopidine
Isopto Carbachol
Levobunolol - Betagan (g)
Lumigan
Miochol-E
Miostat
Phospholine Iodide
Pilocarpine - Isopto Carpine (g)
Timolol Maleate - Timoptic, XE (g)
Trusopt (g)
Xalatan (g)
Betimol; Betoptic S; Humorsol; Travatan
Osteoporosis
Preferred
Alendronate - Fosamax, Weekly (g)
Etidronate - Didronel (g)
Evista
Ibandronate - Boniva (g)
Miacalcin (g)
Actonel, Weekly, with Calcium; Fortical
Over‑the‑Counter Meds
(prescription required for coverage)
Preferred
Acetaminophen - Tylenol (g)
Aluminum hydroxide (g)
Aquasol E (g)
Artificial Tears (g)
Aspirin & Enteric-Coated Aspirin
Bacitracin (g)
Bacitracin/Polymyxin (g)
Benzoyl Peroxide (g)
Betadine (g)
Bisacodyl - Dulcolax (g)
Buffered Aspirin (Bufferin) (g)
Calcium Carbonate (g)
Calcium Citrate (g)
Chlorpheniramine - Chlor‑Trimeton (g)
Cimetidine - Tagamet HB (g)
Clotrimazole - Lotrimin - Mycelex (g)
Condoms (g)
Corticaine (g)
Diphenhydramine - Benadryl (g)
Docusate Calcium - Surfak (g)
Docusate Sodium - Colace (g)
Famotidine - Pepcid AC (g)
Ferrous Gluconate (g)
Ferrous Sulfate (g)
Fleet’s Enema (g)
Hydrocortisone (g)
Loperamide - Imodium (g)
Ibuprofen - Motrin (g)
Ipecac (g)
Kaolin Pectin (g)
Kaopectate (g)
Ketotifen fumerate - Zaditor (g); Claritin
Eye (g)
Lice B Gone (g)
Meclizine - Dramamine II (g)
Miconazole 3 & 7 - Monistat (g)
Mineral Oil Enema (g)
Naphazoline HCl - Clear Eyes (g)
Naphazoline/Phenir Mal - Visine A (g)
Naproxen Sodium - Aleve (g)
Neomy Sulf/Bacitra/Polymxin B Neosporin (g)
Niacin (g)
Nonoxynol 9 - Conceptrol, Delfen, Emko,
Encare, Gyn (g)
Permethrin lotion (g)
Povidone‑Iodine (g)
Pyrethrin (RID) (g)
Sodium Fluoride (g)
Terbinafine - Lamisil, AT (g)
Tioconazole - Vagistat‑1 (g)
Zinc Oxide (g)
Mefanamic Acid - Ponstel (g)
Meloxicam - Mobic (g)
Methadone (g)
Morphine Sulfate IR (g)
Morphine Sulfate SR MS Contin; Oramorph SR (g)
Nabumetone - Relafen (g)
Naproxen Sulfate - Naprosyn (g)
Oxaprozin - Daypro (g)
Oxycodone/Acetaminophen Percocet (g)
Oxycodone/Aspirin - Percodan (g)
Piroxicam - Feldene (g)
Tramadol - Ultram (g)
Tramadol/Acetaminophen - Ultracet (g)
Arthrotec; Avinza; Celebrex; Fentanyl
Citrate - Actiq (g); Fentora; Kadian;
Naprelan; Oxycontin; Prevacid
NapraPAC
Respiratory – Inhaled Beta
Agonist
Preferred
Ventolin HFA
Maxair Autohaler; Qnasl; Xopenex, HFA
Respiratory – Inhaled Steroid
Preferred
Flovent HFA
Pulmicort
QVAR
Asmanex; Alvesco
Respiratory – Intranasal
Steroid
Preferred
Flunisolide nasal spray - Nasalide (g),
Nasarel (g)
Fluticasone Propionate - Flonase (g)
Nasacort OTC
Beconase AQ; Omnaris; QNasl;
Rhinocort Aqua; Veramyst
Respiratory – Miscellaneous
Preferred
Accolate (g)
Acetylcysteine - Mucomyst (g)
Albuterol Sulfate - Vospire ER (g)
Atrovent Inhaler
Combivent
Cromolyn Sodium - Intal solution (g)
Dulera
Intal Inhaler
Ipratropium Bromide - Atrovent
solution, nasal (g)
Singulair
Spiriva
Symbicort
Daliresp; Zyflo, CR
Smoking Cessation
Preferred
Nicotine Replacement
nicotine patches, inhalers, nasal sprays,
Preferred
gum, lozenges
Codeine (g)
Codeine/Acetaminophen - Tylenol #3 (g) Nicotrol (g)
Zyban (g)
Diclofenac Sodium - Voltaren (g)
Etodolac - Lodine, XL (g)
Fentanyl - Duragesic (g)
Chantix
Hydrocodone /Acetaminophen - Vicodin,
ES (g)
Ibuprofen - Motrin (g)
Ibuprofen/Hydrocodone Vicoprofen (g)
Indomethacin - Indocin (g)
Ketoprofen - Orudis; Oruvail (g)
Pain and Arthritis
(g) - Blue Cross Complete provides coverage for the generic equivalent
28
Specialty Drug Guide (Effective April 2015)
Topical Steroids
Preferred
Alclometasone Dipropionate Aclovate (g)
Amcinonide - Cyclocort (g)
Betamethasone Dipropionate Diprolene, AF; Diprosone (g)
Betamethasone Valerate - Valisone (g)
Clobetasol - Clobevate (g)
Clobetasol Propionate - Temovate,
Olux (g)
Desoximetasone - Topicort (g)
Diflorasone Diacetate Florone; Psorcon, E (g)
Fluocinolone Acetonide - Synalar (g)
Fluocinonide - Lidex, Lindane (g)
Fluticasone Propionate - Cutivate (g)
Halobetasol Propionate - Ultravate (g)
Hydrocortisone Butyrate - Locoid (g)
Hydrocortisone (g)
Mometasone Furoate - Elocon (g)
Prednicarbate - Dermatop (g)
Triamcinolone Acetonide Aristocort, Kenolog (g)
Cloderm; Cordran; Halog; Locoid
Lipocream; Luxiq; Olux E; Pandel
Urologic – Benign Prostatic
Hypertrophy
Preferred
Doxazosin Mesylate - Cardura (g)
Finasteride - Proscar (g)
Tamulosin - Flomax (g)
Terazosin - Hytrin (g)
Avodart; Cardura XL; Uroxatral
Urologic – Urinary
Incontinence
Preferred
Oxybutynin Chloride - Ditropan, XL (g)
Detrol, LA; Enablex; Oxytrol;
Sanctura, XR; Vesicare
Psychotropic and
HIV/AIDS Drugs
Coverage for these agents is based
on the Michigan Department of
Health and Human Services criteria.
Please refer to the Magellan website
for additional information:
michigan.fhsc.com/providers/
druginfo.asp
Some drugs require
authorization before Blue
Cross Complete covers
them. Both your doctor
and Blue Cross Complete
must agree that the drug
is medically necessary
based on your condition.
Specialty drugs are medicines for complex or rare conditions, such as arthritis, multiple sclerosis and others. You may fill these
prescriptions by mail.
If you need information about or help getting your specialty drugs, call Pharmacy Customer Service at 1‑888‑288‑3231 from
8:30 p.m. to 6:30 p.m. Monday through Friday. They will help connect you with the specialty pharmacy.
Anticoagulants
Enoxaparin (Lovenox) (g)
Fragmin
Heparin (g)
Innohep
Antineoplastics and cancer
Anastrozole (Arimidex) (g)
Bicalutamide (Casodex) (g)
Eligard
Hycamtin
Leuprolide (Lupron) (g)
Lupron Depot
Revlimid
Targretin
Temodar
Thalomid
Xeloda
Zoladex*
Zolinza
Afinitor
Antivirus and hepatitis
Baraclude
Hepsera
Infergen
Intron A
Pegasys
PEG-Intron
Ribavirin capsules (Rebetol,
Ribasphere) (g)
Ribavirin tablets (Copegus,
Ribapak) (g)
Tyzeka
Chemotherapy and cancer
support medicines
Aranesp*
Leukine
Neulasta*
Neumega
Neupogen
Epogen*
Procrit
Chronic kidney failure and
dialysis
Cystic fibrosis
Pulmozyme
Tobi
Human growth hormone
Genotropin
Humatrope
Increlex (g)
Norditropin
Nutropin
Omnitrope
Saizen
Serostim
Somavert (g)
Tev-Tropin
Zorbtive
Organ transplant and
antirejection
Zortress
Osteoporosis
Forteo
Psoriasis
Enbrel
Humira
Rheumatoid arthritis
Enbrel
Humira
Orencia (g)
Miscellaneous
Actimmune
Exjade (g)
Letairis
Octreotide (Sandostatin) (g)
Syprine
Tracleer
Tyvaso
Ventavis (g)
Gilenya
Multiple sclerosis
Ampyra (g)
Avonex
Copaxone
Extavia
Rebif
Aranesp*
Epogen*
(g) – Blue Cross Complete provides coverage for the generic equivalent
*These drugs are not available at a retail pharmacy and must be administered at a physician’s office.
This list is current as of the date on the back of this handbook.
For our most updated list, visit us online at MiBlueCrossComplete.com.
29
Xenazine
Part 4: Guidelines to
good health
Take the guidelines to your next doctor’s visit. Review them with your
doctor to see if you need any tests or shots. If you have health risks or a
chronic condition, talk to your doctor. He or she will work with you to make
sure you get the care that’s best for you.
Good health for adults
With your doctor and Blue Cross Complete, you have a health care team.
Your team will support you, coach you and help you make the health care
decisions that are best for you.
There are four key healthy behaviors all men and women can practice. These
behaviors help people get and stay healthy. They also reduce the risk of
illness and chronic conditions. They are:
This team centers around you. You are the most important member of
your health care team. You get the best care when you’re directly involved
in making health care choices for yourself.
• Eat healthy, balanced meals in moderation. Eat five or more servings
of fruits and vegetables a day and less saturated fat. This may reduce
the risk of cancer and other chronic diseases.
The healthy choices you make impact your health. When you make healthy
choices, you can prevent or manage chronic illnesses such as heart disease
and diabetes.
• Exercise. Thirty minutes of moderate physical activity most days of the
week will keep you fit and help prevent disease. Exercise can be cutting
the grass, dancing, swimming or just walking. The important thing is to
get moving.
Health information to support your health
goals
• Have a well visit once a year. See your doctor each year for a checkup.
Your doctor will make sure you get the tests, screenings and vaccines
that are right for you. Examples are mammograms for women, prostate
exams for men or even flu shots. If problems are found early, they’re
easier to treat.
One way Blue Cross Complete provides healthy living support is by giving
you access to health education resources. These can help you stay healthy,
get better and improve your quality of life. We want you to have the clear
information you need to make smart health care choices.
• Don’t smoke. If you’re middle-aged, smoking triples your risk of heart
disease. If you use tobacco, join our free tobacco quit program. Learn
more in Part 2: Your health care benefits.
• Member health magazine. We mail our Good Health magazine to
members three times a year. It tells you more about your benefits, gives
you tips to stay healthy and other news.
In addition to these four healthy behaviors, all adults should know four basic
health numbers. These numbers help you and your doctor understand your
risk for serious illnesses. The numbers to know are:
• Free booklets and health education. To learn about any health topic,
such as eating right, heart health and more, call our Outreach Team.
Team members can help you get the information you need.
• Health care reminders. We sometimes mail you cards or call you to
remind you about important health tests, screening and shots. We may
send you other health reminders, too.
• Online help and information. You can find health resources on our
website.
Outreach Team
1-888-288-1722
8 a.m. to 5:30 p.m.
• Access to discount programs. Your Blue Cross ID card gives you
discounts through our Healthy Blue XtrasSM savings program. This
program gives you special member discounts and offers for a variety of
healthy products and services from Michigan companies. Learn more
about these discounts at bcbsm.com/xtras.
• Blood sugar (glucose) level. A blood sugar test measures the average
amount of glucose, or sugar, in your blood. It’s used to determine if you
have diabetes or if your diabetes is well controlled.
Our Guidelines to Good Health recommends the health counseling,
screenings and vaccines you need for your age and gender.
30
• Blood pressure. Blood pressure measures how your blood moves
against your arteries during and between heart beats. High blood
pressure is dangerous and often has no symptoms. It raises your risk for
heart disease, stroke, kidney disease and blindness.
• Cholesterol level. Keeping the right levels of the cholesterol and other
fats in your cells can reduce your risk for heart disease, stroke and other
conditions. The results of this blood test can help you and your doctor
understand your risks.
Guidelines to good health
Use the guidelines to make sure that you and your family are up-to-date on
the health services you need to be healthy. We cover all the services in the
guidelines.
• Body mass index. Body mass index, or BMI, compares your height to
your weight. Your BMI indicates your level of body fat, and may put you
at risk for weight-related health conditions — whether your BMI is low
or high.
Learn more about the
guidelines for adults and
children in this section.
Another important part of your overall health is your stress level. Stress can
undermine your health. If stress is causing you to eat poorly, drink too much,
smoke or neglect your health, you need to take time to be good to yourself.
31
1-800-784-8669
8 a.m. to 1 a.m.
seven days a week
Before you get pregnant
Pay attention to your health. Make healthy living a part of your life.
If you need help managing stress, you can call a network mental health
professional without a referral. For help finding one near you, call Customer
Service. For help with other health questions, call our Outreach Team or our
Health checks for adults
Use this quick check list to track your overall health.
Talk to your doctor about what’s best for you.
Your doctor is your partner in care. Tell your doctor if you are planning to
become pregnant. This discussion is very important for you and your future
baby. We also cover family planning.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
You and your doctor can talk about health issues that might increase your risk
of problems during pregnancy. These issues may include diabetes, risks in
your surroundings, smoking, substance use and other health concerns. Your
doctor can help you be healthy before, during and after your pregnancy.
Once you are pregnant
When you’re pregnant, you’ll see your doctor very often. Talk to your doctor
about:
Annual well visit – date: _________
• Exercising during pregnancy
Height and weight check
• Taking multivitamins with iron and folic acid
Height _______ft. _______in.
• Breast feeding
Weight _______lbs.
• Sexually transmitted diseases
Body mass index (BMI) _________
Also, take these safety measures:
Blood pressure: ________ / ________mm/Hg
• Avoid smoking and don’t be around other people who are smoking
Total cholesterol
• Don’t use alcohol or drugs without checking with your doctor
Cholesterol ________mg/dL
• Eat a balanced and healthy diet
LDL ________mg/dL
• Wear a seatbelt (lap and shoulder) in the car
HDL ________mg/dL
1-888-288-1724
24 hours a day,
seven days a week
Triglycerides ________mg/dL
A1C: _________%
Flu shot – date: _________
Pneumonia shot – date: _________
You may also want to:
• Ask our Outreach Team about our pregnancy programs and other
resources
• Join a childbirth class or parent support program
While you are expecting
Staying healthy is important to both moms and babies. See your doctor as
early as possible and keep all your appointments. Follow your doctor’s
directions and ask questions. These visits are covered by Blue Cross
Complete.
Good health for pregnant women
All pregnancies are different. Even if you’ve had a baby before, it’s important
to get regular prenatal and postpartum care. Prenatal and postpartum visits
keep you and your baby healthy.
Blue Cross Complete has a pregnancy program for soon-to-be parents.
Bright Start® is a special program for our pregnant members. We want to
make sure you have all you need for a healthy pregnancy and baby. Our
Outreach Team can tell you more about the Bright Start program.
If you’re pregnant, it’s important to get medical care right away. Blue Cross
Complete covers care for women who are pregnant, thinking about
becoming pregnant or who have just had a baby.
At a minimum, low-risk women should have about eight prenatal visits.
Women with high-risk pregnancies will need more care. Your doctor and
Blue Cross Complete will work with you to make sure you get the care you
and your baby need. All women need a postpartum visit after a pregnancy.
You can also get help for you and your baby from Michigan’s Maternal Infant
Health Program. Learn more in Part 2: Your health care benefits.
Did
you
know?
Your primary care doctor
coordinates all your care. Call
him or her first for all your
health care needs.
32
After your baby is born
It’s just as important to take care of yourself after you have a baby. You
should have a postpartum checkup 21 to 56 days after your pregnancy. This
exam is covered by Blue Cross Complete.
33
Outreach Team
1-888-288-1722
8 a.m. to 5:30 p.m.
The standard childhood vaccines protect against:
The doctor may check your blood pressure and your weight. He or she may
talk to you about birth control, breast feeding and provide other postpartum
counseling. You can also talk to your doctor about any new feelings you may
have.
• Diphtheria, tetanus and pertussis (whooping cough)
•Polio
• Measles, mumps and rubella
•Chickenpox
Health checks for new moms
•Rotavirus
Use this quick check list to track your pregnancy
care. Talk to your doctor about what’s best for you
and your baby.
• Hepatitis B
• Hepatitis A
Planning a pregnancy?
• Haemophilus influenzae type b disease or Hib disease
Practice good habits before you become
pregnant:
• Pneumococcal disease
Both Hib and pneumococcal disease can cause pneumonia, meningitis and
other serious illnesses in young children.
q Eat a well-balanced diet
q Strive for a healthy weight
Teens may also need boosters and some vaccines, such as a meningitis
booster or the human papillomavirus vaccine. Please refer to the Guidelines
to Good Health and talk to your child’s doctor.
q Kick bad habits, such as smoking
q Don’t use drugs or alcohol
Prenatal visits
q 6 – 8 weeks date:________________
q 14 – 16 weeks date:________________
q 24 – 28 weeks date:________________
Health checks for children
q 32 weeks date:________________
q 36 weeks
date:________________
Use this quick check list to track your child’s well
visits. Talk to your doctor about what’s best for
your child.
q 38 weeks
date:________________
q 40 weeks
(once a week until
baby is born) Schedule well visits for the following ages:
q 1 month date:________________
q 2 months date:________________
Postpartum visit
q 4 months date:________________ q 21 – 56 days
after delivery
q 6 months date:________________ q 9 months date:________________ q 12 months date:________________ q 15 months date:________________ date:________________
date:_______________
Your child may also have these well visits:
Good health for children and teens
Each child develops and grows on his or her own schedule. Regular
well-child visits and scheduled vaccines can keep your child on track. Talk to
your doctor about what shots and screenings are right for you or your child.
During your children’s well visits, you doctor will make sure your child is
current on the tests, screenings and vaccines that are best for him or her.
Your doctor may also check your child’s growth and development. These
developmental screenings help make sure your child is growing as he or she
should for his or her age and gender.
34
Did
you
know?
q 18 months date:________________ q 24 months date:________________ q 30 months date:________________ q Age 3 to 6: At least one well visit per year
q Age 6 to 21: One well visit per year
In the U.S., 70 percent of all
prescriptions are filled with
generic medicine.
Did
you
know?
Generic drugs have the same
active ingredients as the brand
name versions.
35
Guidelines to Good Health
for children and teens
Guidelines to Good Health for adults
These guidelines can help you prevent illness or find conditions early. Your doctor may suggest a different
schedule based on your needs.
Regular well-child visits and scheduled immunizations for childhood disease can help keep your child on track.
Talk to your child’s doctor about what schedule is right for him or her.
Heart healthy tip: Ask your doctor about aspirin use.
What
Age
How often
Screening for men and women
What
Age
Screening for women
How often
Health exam
(including, height &
weight assessment,
body mass index
evaluation and
obesity counseling,
alcohol/drug abuse,
tobacco use and
injury)
18–49
Cholesterol and lipid 20–45+
screening
Ask your doctor
Osteoporosis
screening
50–64
Ask your doctor
65+
Test
Cervical cancer
Pap smear
18–65
Every 3 years after
becoming sexually active
Blood pressure
screening
18+
50–65+
Every 1–5 years
Every 1–3 years
Mammography
Every two years if BP is at
or less than 120/80
Every year if BP is higher
than 120–139/80–89
Diabetes screening
Colon cancer
screening
18–65+
18–49
50+
76+
Age
How often
What
Well-child exam
Parental education:
nutrition; development;
injury and poison
prevention; SIDS; coping
skills; tobacco use
screening; secondhand
smoke; height, weight
and body mass index
0–24 months
11 visits
Immunizations
2–18 years
8 visits
Neonatal and hearing
screening
Birth (after
24 hours)
Once at birth
66+
Ask your doctor
18–39
Ask your doctor
40–74
Every 2 years
75+
Ask your doctor
Cholesterol screening
2+ years
Ask your doctor
Every year if sexually active
Blood lead testing
12 and 24
months
Twice
Vision screening
2–6 years
Before starting school
7–12 years
Every 2 years
13–21 years
Every 3 years
12+ years
or earlier if
sexually active
Every year
Chlamydia screening Under 24
More frequently if needed
25+
Every year if high risk
Every 3 years with BP at or
higher than 135/80
Pregnant
women
Screen
Childbearing
Week 6–8 = first visit
Week 14–16 = 1 visit
Week 24–28 = 1 visit
Week 32 = 1 visit
Week 36 = 1 visit
Week 38–41 = weekly visit
Preconception and
pregnancy: prevention
and counseling
Once 21–56 days after
delivery
Cervical cancer Pap
smear
Age 13–21
Every 3 years if
sexually active
Chlamydia and sexually
transmitted infection
screening, including
HIV screening
Age 13–21
Every year if sexually
active
Pregnancy prenatal
visits
If high risk — ask your
doctor
Fecal occult blood test
every year
OR
Sigmoidoscopy every
5 years with fecal occult
blood test every 3 years
OR
Colonoscopy every
10 years
Pregnancy
postpartum
HPV (human
papillomavirus)
Females 9–26 3 doses
Males 9–21
3 doses
Ask your doctor
Tdap
After age 12
1 dose
Tetanus
18–65+
Once every 10 years
Flu
18–65+
Every year
MMR
18–49
1–2 doses if needed
Glaucoma screening
18–64
If high risk — ask your
doctor
HIV screening
18–64
One test for everyone
18–65+
Every year if high risk
Cholesterol and lipid 35+
screening
Every 5 years; more often
with risk factors
Prostate cancer
Ask your doctor
Childbearing
Immunizations for men and women
Screening for men
50–74
What
Varicella (chickenpox) 18–65+
2 doses if needed
Hepatitis A,
Hepatitis B,
Meningococcal
18–65+
If high risk
Pneumococcal
(meningitis and
pneumonia)
18–64
If high risk
65+
1 dose for everyone 65 and
older; revaccinate at age 65
if first vaccine was received
before age 65 and 5 years or
more have passed since that
first dose was given
Zoster (shingles)
36
60+
Age
How often
HPV (human
papillomavirus)
Females 9–26
3 doses
Males 9–21
3 doses
DTaP
2, 4, 6 months
1st, 2nd, 3rd dose
15–18 months
4th dose
4–6 years
5th dose
Rotavirus
2–6 months
Complete series
Tdap
11–12 years
1 dose
Hepatitis A
12 months
1st dose
18–24 months
2nd dose
Birth
1st dose
1–2 months
2nd dose
6–18 months
3rd dose
2 months
1st dose
4 months
2nd dose
6–18 months
3rd dose
4–6 years
4th dose
HiB-haemophilus
2–15 months
Complete series
Flu
6 months–
8 years
2 doses first year,
then every year
Age 9–21 years
Every year
12–15 months
1st dose
4–6 years
2nd dose
12–15 months
1st dose
4–6 years
2nd dose
11–12 years
1st dose
16–18 years
Booster
2 months
1st dose
4 months
2nd dose
6 months
3rd dose
12–15 months
4th dose
Hepatitis B
IPV-polio
For girls
MMR
Varicella (chickenpox)
Meningococcal
Pneumococcal
Conjugate-pneumonia
These guidelines are based on recommendations from national medical organizations and the most current
medical and scientific research.
1 dose
37
Part 5: Healthy
Michigan Plan
Your card image may
look slightly different.
Enrollee Name
VALUED CUSTOMER
About the Healthy Michigan Plan
Enrollee ID
XYU888888888
Issuer (80840)
The Healthy Michigan Plan is a health care program from the Michigan
Department of Health and Human Services. You have chosen to get your
Healthy Michigan Plan care and services from Blue Cross Complete.
9101000021
M12345678
This handbook explains how to get the benefits, care and services covered
by the Healthy Michigan Plan. It also describes the additional rights and
responsibilities you have under the Healthy Michigan Plan.
These benefits are in addition to the ones you have as a Blue Cross
Complete member. You can read about all your benefits and responsibilities
in this handbook.
Your Blue Cross Complete member ID card
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Enrollee Name:
Your name
2
Enrollee ID:
Identifies your
record in our files
3
Beneficiary ID:
Number assigned
to you by the state
HMO
• A magnetic strip
to help providers
Blue Cross Complete
RxBIN
600428
P.O. Box 7355
06210000
London, KY 40742
process RxPCN
claims
in
your
local BCBS plan. Out-of-state services
Group Number
the future. It has
00277723
information from
Pharmacy claims:
P.O. Box 516
Essington, PA 19029
the front of the card
PerformRx
and your birth date.
It doesn’t have any
benefit or health information.
TTY/TDD:
PerformRx:
888-987-5832
888-288-3231
Dental - Healthy Michigan Plan: 844-320-8465
abuse treatment:
888-288-1722
Providers Only:
and inquiries:
888-312-5713
and inquiries:
888-989-0057
855-232-7640
• Toll-free Customer Service numbers and other important numbers.
What the Healthy Michigan Plan covers
As a Blue Cross Complete member, you have all the benefits listed in the
Blue Cross Complete Member Handbook. Learn more about these benefits
in Part 2: Your health care benefits.
Members who also have the Healthy Michigan Plan have additional benefits
and responsibilities. This section explains these.
Dental services
We’ll send you your Blue Cross Complete ID card. You may also use this card
to get dental care.
1
Plan
Ph ar macy Ben efits Ad min istr ato r
You will need to show your Blue Cross Complete ID card each time you visit
your doctor or a hospital. You will also need it to fill prescriptions. It’s
different than 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
On the back of your ID
card, you’ll find:
MiBlueCros s Complet e.com
The Healthy Michigan Plan covers some dental care, including dental exams,
cleanings and extractions.
MiBlueCros s Complet e.com
Enrollee Name
1 VALUED CUSTOMER
Plan
HMO
Enrollee ID
2 XYU888888888
5
Issuer (80840)
9101000021
3 M12345678
4
Group Number:
Shows the group in which you’re enrolled
5
RxBIN & RxPCN: Drug plan numbers
6
Rx: Shows you have drug coverage
RxBIN
RxPCN
600428
06210000
Group Number
4 00277723
6
You will get dental care from Blue Cross Complete’s network dental
providers. To find a dentist or to see if your dentist is in our network, call
Dental Customer Service.
TTY/TDD:
Blue Cross Complete
P.O. Box 7355
London, KY 40742
your local BCBS plan. Out-of-state services
Pharmacy claims:
P.O. Box 516
Essington, PA 19029
Dental - Healthy Michigan Plan: 844-320-8465
abuse treatment:
888-288-1722
Providers Only:
and inquiries:
888-312-5713
and inquiries:
888-989-0057
855-232-7640
PerformRx
Ph ar macy Ben efits Ad min istr ato r
PerformRx:
Habilitative services
888-987-5832
888-288-3231
The Healthy Michigan Plan covers habilitative services ordered by your
doctor. Habilitative services help a person keep, learn or improve skills and
functioning for everyday life.
Habilitative services may include speech, physical or occupational therapy.
They may also include equipment to help a person walk or move around and
related supplies.
Hearing care
In addition to the hearing care covered by Blue Cross Complete, the Healthy
Michigan Plan also covers hearing aids. This includes your fitting and the
batteries.
Preventive care
Blue Cross Complete covers many preventive care services. The Healthy
Michigan Plan covers additional preventive care. These services are
recommended by national organizations such as the United States Preventive
Services Task Force.
38
Dental Customer Service
1-844-320-8465
9 a.m. to 5 p.m.
Monday through Thursday
9 a.m. to 3:30 p.m. Friday
39
Learn more about covered
therapies, services and
equipment in Part 2:
Your health care benefits.
How the Healthy Michigan Plan works
Get rewarded for making healthy choices
Good health care involves a health care team to coordinate your care and
help you make health care choices. Your doctors are part of this team and so
is Blue Cross Complete.
You may qualify for rewards by completing a Health Risk Assessment form
with your doctor and committing to make healthy choices. These choices
may include quitting smoking, losing weight, lowering your blood pressure
or cholesterol, or getting a flu shot.
You are the most important member of this team. When you’re directly
involved in your health care, you get better care. We support your healthy
choices, and the Healthy Michigan Plan has some tools to help.
Rewards may be a $50 gift card or a 50-percent reduction in your
cost-sharing contribution, depending on your income.
To qualify for your reward:
Making healthy choices
Blue Cross Complete and the Healthy Michigan Plan want to help you make
healthy choices. Healthy choices can help prevent serious illnesses such as
heart disease and diabetes.
1.Within 60 days (about two months) of joining Blue Cross Complete,
make an appointment with your primary care doctor. You should see
your doctor within 150 days (about five months) of joining our plan.
Your healthy choices may also save you money. When you make healthy
changes, your cost-sharing amounts may be reduced.
2.Fill out Sections 1, 2 and 3 of the Health Risk Assessment form, including your name and address.
Seeing your primary care doctor
3.Take your form to your doctor’s appointment. Your doctor will
complete Section 4 and return the entire form to Blue Cross Complete.
Your primary care doctor is the doctor you see the most. He or she is part of
your health care team and will help you get the care you need.
Fill out this form when you join Blue Cross Complete. It should be filled out
once a year. If you need a form, please call Customer Service.
You will need to make an appointment to see your primary care doctor within
60 days, about two months, after you enroll in Blue Cross Complete. See the
doctor for your appointment within five months, or about 150 days.
Letting your wishes be known — advance directives
Blue Cross Complete respects your right to accept or refuse any medical
treatment. An advance directive is a written statement of your wishes for
medical care. It explains what treatments you want or don’t want when you
can’t speak for yourself.
During this appointment, you and your doctor will complete a health risk
assessment.
Completing a health risk assessment
A health risk assessment is a form you and your doctor fill out. It helps your
health care team see how healthy you are and find ways to help you be
healthier. The assessment gives you and your doctor a place to start making
the health care choices that are right for you.
During the health assessment, you and your doctor will talk about:
As part of the Healthy Michigan Plan, we’d like you to fill out an advance
directive. We will provide you with a form to do this. Please complete the
form and follow the return instructions.
Learn more about cost sharing
in Paying your cost sharing in
this section.
• Your body mass index
Learn more about advance
directives in Part 7: Update your
personal records.
If you have questions, you can call Customer Service.
Paying your cost sharing
Cost sharing refers to two different kinds of payments you may make for your
Healthy Michigan Plan benefits. One kind of payment is your contribution.
The other is your copay. Your cost-sharing amount may change if you adopt
healthy behaviors.
• Your blood pressure
• Your total cholesterol
• Diabetes testing, such as A1C
Your contribution
• If you use tobacco
Your contribution is an amount you may pay to share the cost of your Healthy
Michigan Plan benefits. This helps offset the total cost of your care.
• Flu vaccines
Your copays
Did
you
know?
A copay is a small amount of money you pay each time you get health care.
The Healthy Michigan Plan has copays for most services. Members who have
the Healthy Michigan Plan will pay most copays to Blue Cross Complete, not
to the providers.
You can see a network OB-GYN
without a referral.
40
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
41
Supplemental Certificate of Coverage for
Healthy Michigan Plan members
The services that require a copay and the amount are:
Type of service
Copay
(only members age 21 and older pay
copays)
Physician office visit
$2 per visit
Pharmacy
$3 for each name brand drug
$1 for each generic brand drug
Vision care
$2 per visit
Dental care
$3 per visit
Hearing aids
$3 per aid
Chiropractic
$1 per visit
Podiatry
$2 per visit
Hospital emergency room visit
$3 per visit
Outpatient hospital visit
$1 per visit
Inpatient hospital stay
$50 for the first day of the hospital stay
You have all the benefits of Blue Cross Complete of Michigan, as listed in the
Blue Cross Complete Member Handbook and Certificate of Coverage.
The Healthy Michigan Plan is a program operated under an 1115 Waiver
approved by the Center for Medicare and Medicaid Services to provide
Medicaid coverage to all adults in Michigan with incomes up to and
including 133 percent of the Federal Poverty Level.
About this certificate
This certificate has been applied for as Healthy Michigan overage. This
certificate sets the terms and conditions of Coverage and describes the
health care services that are covered for Members under the Healthy
Michigan Plan.
Cost sharing information
Cost sharing refers to the two types of payments you may make for your
health services. It includes contributions and copays. Your cost sharing
amount may change if you adopt healthy behaviors.
There are no copays for:
Cost sharing cannot exceed 5% of your income. It is mandated by the
Michigan Department of Health and Human Services.
• Family planning products or services
• Any pregnancy-related products or services or if you are pregnant
Contributions
• Services related to preventive care
• Services related to chronic conditions, such as heart disease and
diabetes
The Healthy Michigan Plan requires people with annual incomes between
100% and 133% percent of the Federal Poverty Level to contribute 2% of
annual income as a contribution.
• Services received at a Federally Qualified Health Center
Copays
Some covered services have a copay. A copay is a small amount of money
you pay each time you get health care. Copays are paid to Blue Cross
Complete. Only members age 21 and older pay copays.
Reducing your costs
You may be able to reduce your cost sharing by engaging in healthy
behaviors.
The services that require a copay and the amount are:
Your MI Health Account
You will pay your cost sharing through a special health care account called
the MI Health Account. Every three months, you’ll get a MI Health Account
statement. The statement will show:
• The health care services you had
• How much Blue Cross Complete paid
• How much you have paid
• Your copays, if any
• Your contribution amount, if any
• If you owe any amount
Did
you
know?
• How to pay, if you owe
You will get more information about the MI Health Account and how to
use it.
42
Your child can see a network
pediatrician without a referral.
Type of service
Copay
(only members age 21 and older pay
copays)
Physician office visit
$2 per visit
Pharmacy
$3 for each name brand drug
$1 for each generic brand drug
Vision care
$2 per visit
Dental care
$3 per visit
Hearing aids
$3 per aid
Chiropractic
$1 per visit
Podiatry
$2 per visit
Hospital emergency room visit
$3 per visit
Outpatient hospital visit
$1 per visit
Inpatient hospital stay
$50 for the first day of the hospital stay
Did
you
know?
43
Talk to a nurse anytime. We
have a free 24-hour Nurse
Help Line.
There are no copays for:
Part 6: MIChild
• Family planning products or services
• Any pregnancy-related products or services or if you are pregnant
You’ve chosen to get your MIChild care and services from Blue Cross
Complete. You have all the benefits, care and services covered by the
MIChild program and Blue Cross Complete. This handbook explains this
information.
• Services related to preventive care
• Services related to chronic conditions, such as heart disease and
diabetes
• Services received at a Federally Qualified Health Center
Families with children who are enrolled through MIChild pay $10 a month for
all eligible children in the family. If you have questions about your MIChild
premiums, call MIChild at 1-888-988-6300 (TTY: 1-888-263-5897).
Dental services
Diagnostic, preventive, restorative, prosthetic and medically/clinically
necessary oral surgery services, including extractions, are covered. The
Department of Health and Human Services website contains the list of
covered services.
Dental services for MIChild members age 18 and younger are provided
through Healthy Kids Dental. To find a Healthy Kids Dental provider, call
1-800-482-8915.
MIChild is a health care program from the Michigan Department of
Health and Human Services for children age 18 and younger. Blue Cross
Complete administers MIChild benefits to eligible members. Habilitative services
Habilitative services are services that help a person keep, learn or improve
skills and functioning for daily living. These services may include physical and
occupational therapy, speech language pathology and other services.
Hearing care
Hearing exams and hearing aid evaluations are available from a network
provider. We cover the purchase and fitting of hearing aids, including
batteries.
When a hearing aid is recommended following a hearing examination
conducted while a Member of Blue Cross Complete, the following is covered
for each Member once each fifth benefit year:
• Hearing aid examination to evaluate the Member for the specific type
or brand of hearing aid needed;
• One single hearing aid unit (or one per ear if medically necessary)
including earphone (receiver or oscillator), ear mold, necessary cords,
tubing, and connections. The hearing aid unit must be a conventional
amplification device. It must also be an in-the-ear, behind-the ear or
on-the-body type, and identified as basic to the Member’s amplification
requirements;
• Fitting of the hearing aid including one follow-up visit to evaluate the
performance of the hearing aid and determine its conformance to
prescription; and
• For all members, batteries, maintenance, and repair for hearing aids are
covered.
Payment: The amount that would be paid by Blue Cross Complete for a
conventional hearing aid unit may be applied toward an upgraded aid, if
desired by the Member.
Exclusions
Medicare and other federal or state government programs
If you obtain Medicare coverage you will be disenrolled from the Healthy
Michigan Plan.
44
Did
you
know?
Get where you’re going. Our
free ride service can help you
get to your covered services.
45
Part 7: Update your
personal records
If your wishes aren’t followed
If you have a complaint about how your provider follows your advance
directive, you may write:
If your family changes
Changes in your family may affect your benefits. These may include when you:
• Have a baby
• Adopt a baby or gain legal guardianship of a child
Department of Licensing & Regulatory Affairs
BHCS/Enforcement Division
P.O. Box 30670
Lansing, MI 48909-8170
Call: 517-373-9196
The Bureau of Health Care Services website is michigan.gov/healthlicense.
Click on Complaints, then How to File a Complaint.
• Get married
• Get divorced
• Change your address
If you have any of these changes, tell Customer Service and your DHS case
worker when the change happens.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
If you have complaints about how Blue Cross Complete follows your wishes,
you may call the state of Michigan’s Department of Insurance and Financial
Services. Call toll-free at 1-877-999-6442 or go to michigan.gov/difs.
Make your wishes known: Advance
directives
Blue Cross Complete respects your right to accept or refuse any medical
treatment. An advance directive is a written statement of your wishes for
medical care. It explains what treatments you want, or don’t want, when you
can’t speak for yourself.
Durable power of attorney for health care: The state of Michigan only
recognizes an advance directive called a durable power of attorney for
health care. To create one, you will need to choose a patient advocate.
This person carries out your wishes and makes decisions for you when you
cannot. It’s important to pick a person you know and trust to be your
advocate. If you don’t choose someone, your doctor, a court, a legal
guardian or a family member will be your advocate.
Living will: A living will is another type of advance directive. Living wills are
not enforceable under Michigan law.
Visit us online:
More information and the forms you need to write an advance directive are
available by calling Customer Service or going to our website.
Talk to your family and primary care physician about your choices. File a copy
of your advance directive with your other important papers. Give a copy
to the person you designate as your patient advocate. Ask to have a copy
placed in your medical record.
If your primary care doctor cannot agree to your choices in your advance
directive, you may want to change your primary care doctor.
Did
you
know?
Call Customer Service for more information and the forms you need to
write an advance directive. Or visit michigan.gov and search for “advance
directives.”
46
Follow up with your doctor
within 24 hours after an urgent
care or emergency room visit.
47
Part 8: Your rights and
responsibilities
Member responsibilities
You have the responsibility to:
• Know your Blue Cross Complete certificate
• Know your member handbook and all other provided materials
As a member of Blue Cross Complete, you have rights and responsibilities.
Understanding these rights and responsibilities helps you get the most of
your health care benefits.
• Call Customer Service with any questions
• Seek services for all nonemergency care through your primary care
physician
Member rights
• Use the Blue Cross Complete provider network
Member rights will be honored by all Blue Cross Complete staff and affiliated
providers. You have the right to:
• Understand information about your health care
• Be referred and approved by Blue Cross Complete and your primary
care physician for out-of-network services
• Get required care as described in this book
• Make and keep appointments with your primary care physician
• Be treated with dignity and respect
• Contact your doctor’s office if you need to cancel an appointment
• Privacy of your health care information, as outlined in this handbook
• Be involved in decisions regarding your health
• Treatment choices, in spite of cost or benefit coverage
• Behave in a proper and considerate manner to providers, their staff,
other patients and Blue Cross Complete staff
• Fully join in making decisions about your health care
• Refuse to accept treatment
• Tell Blue Cross Complete of address changes, any changes for your
dependent coverage and any other health coverage
• Voice complaints, grievances or appeals about Blue Cross Complete
and its services, benefits, providers and care
• Protect your ID card against misuse
• Call Customer Service right away if your card is lost or stolen
• Get clear and easy-to-understand written information about Blue Cross
Complete’s services, practitioners, providers, rights and responsibilities
• Follow your doctor’s instructions regarding your care
• Review your medical records and ask that they be corrected or amended
• Make treatment goals with your physician
• Make suggestions regarding Blue Cross Complete’s rights and
responsibilities policies
• Contact the Blue Cross Complete Anti-fraud Unit if you suspect fraud
For more information, please contact Customer Service.
• Be free from any form of abuse, being restrained or secluded, as a
means of coercion, discipline, convenience or retaliation when receiving
services
Your additional rights and responsibilities
In addition to these rights and responsibilities, you also have these rights:
• To ask for and get information about how our company is structured
and operated
• Request and receive:
– The Blue Cross Complete provider directory
• To have your health information stay confidential
– The professional education of your providers, including those who
are board certified in the specialty of pain medicine for evaluation
and treatment
• To use your rights without changing the way you are treated by us, your
health care providers or the state of Michigan
– The names of hospitals where your physicians are able to treat you
• To ask for the professional credentials of your provider
– The contact information for the state agency that oversees
complaints or corrective actions against a provider
• To ask for any prior authorization requirements, limits, restrictions or
exclusions
– Any authorization, requirements, restrictions or exclusions by service,
benefit or a specific drug
– The information about the financial agreements between Blue Cross
Complete and a participating provider
48
Did
you
know?
If you can’t keep your
appointment, try to reschedule
24 hours in advance.
• To ask about the financial responsibility between Blue Cross Complete
and any network provider
• To know if there are any provider incentives, such as pay-for-performance
• To ask about stop loss coverage
49
Did
you
know?
Your primary care doctor
coordinates all your care. Call
him or her first for all your
health care needs.
You also have the responsibility to tell your doctor and Blue Cross Complete
about your health and health history. Telling us helps us give you the care
and treatment that’s right for you.
If you notice any problems or want to report fraud or abuse, write:
Healthy Michigan Plan members: You have all the rights and
responsibilities of Blue Cross Complete. You also have additional
responsibilities. Learn more in Part 5: Healthy Michigan Plan.
Help identify health care fraud
Blue Cross Complete Anti-fraud Unit
PO Box 018
Essington, PA 19029
Or call toll-free: 1-855-232-7640 (TTY users should call 711)
Or email: [email protected]
You may also report or get more information about health care fraud by
writing:
Medicaid pays doctors, hospitals, pharmacies, clinics and other health care
providers to take care of adults and children who need help getting medical
care. Sometimes, providers and patients misuse Medicaid resources.
Office of Health Services Inspector General
P.O. Box 30062
Lansing, MI 48909
Or call toll-free: 1-855-MI-FRAUD (1-855-643-7283)
• Fraud is purposefully misrepresenting facts.
Or visit: michigan.gov/fraud
• Waste is carelessly or ineffectively using resources.
Information may be left anonymously.
Unfairly taking advantage of Medicaid resources leaves less money to help
other people who need care. This is called fraud, waste and abuse.
• Abuse is excessively or improperly using those resources.
Help us fight fraud
Blue Cross Complete works to find, investigate and prevent health care
fraud. You can help. Know what to look for when you get health care services.
If you get a bill or statement from your doctor or an Explanation of Benefit
Payments statement from us, make sure:
• The name of the doctor is the same doctor who treated you
• The type and date of service are the same type and date of service you
received
• The diagnosis on your paperwork is the same as what your doctor told
you
Health care fraud is a felony in Michigan
Some common ways fraud is committed include:
• Letting someone else use your Medicaid ID card. Only you have
permission to use your card to get covered services.
• Falsifying medical bills, claims and other documents.
• Using an expired ID card to obtain products or services.
• Trying to get payment from multiple insurance policies for the same
illness or injury.
Anti-fraud Unit
1-855-232-7640
24 hours a day,
seven days a week
Being involved in fraud, waste or abuse can put your benefits at risk or make
other legal problems. Help minimize fraud, waste and abuse. If you suspect
fraud, you can report it anonymously by calling our 24/7 anti-fraud hotline.
Did
you
know?
In the U.S., 70 percent of all
prescriptions are filled with
generic medicine.
50
51
Part 9: If you have
a concern
To ask for an appeal review in person: You can also ask to appeal in
person. If you would like to present your appeal in person, we will set up a
meeting date and time. We also can provide you with a ride to this meeting.
To have someone else ask for an appeal review for you: You can ask for a
review yourself. Or, your doctor or someone else you choose can make this
request for you. If you want another person to represent you, you must give
that person written permission to do so.
Grievances and appeals
Blue Cross Complete and your doctor want you to be satisfied with the
services you receive.
State and federal rules require that this permission be made after you get
our denial notice. It also must be specific to the service in question.
Appeals generally relate to your medical coverage. Grievances are
complaints about other aspects of your care or service.
To give another person permission, fill out an Authorization of a Member
Representative form. Complete and sign your form, and return it to the
address on the form. Customer Service can send you this form.
If you have a problem relating to your care, please talk to your doctor. Your
doctor can often fix the problem. You can always call Customer Service with
any questions or problems you may have.
If your concern or complaint cannot be fixed by your doctor or Customer
Service, you may file a grievance.
Grievances
If you aren’t happy with us or your doctor, you can file a complaint. We will
keep your complaint private. You can file a complaint by writing or calling us:
Member Grievances
Customer Service
Blue Cross Complete
1-800-228-8554
P.O. Box 41789
North Charleston, SC 29423 TTY: 1-888-987-5832
If you send a written complaint, we will let you know that we received it. We
will let you know within 30 days that your grievance has been addressed.
You can also ask to present your grievance in person. If you would like to
present your grievance in person, we will set up a meeting date and time.
We also can help you get a ride to this meeting.
Healthy Michigan Plan members: To file a complaint about dental
services, write, fax or call:
Blue Cross Complete
P.O. Box 2819
Detroit, MI 48202-3231
Fax: 313-875-2401
1-844-320-8465
9 a.m. to 5 p.m. Monday through Thursday
TTY: 711
Appeals
You may disagree with a decision we make about paying for a medical
treatment, service, equipment or medicine. We will send you a written notice
called a denial notice. You have the right to appeal our decision.
An appeal means you ask us to review our decision. If you have questions or
need help with the appeal process, please call Customer Service. TTY users
should call 1-888-987-5832.
Types of review — standard and expedited
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
Standard review (30 days): You can ask for a standard review by writing or
calling us. If you need help writing a letter, please call Customer Service.
You can also send us any paperwork, medical records or other items that
support your appeal. We will send you a letter when we receive your request
for review. We’ll respond to your request within 30 days. We may need an
extra 10 days if we’re waiting for records from your provider. Write, call or fax:
Member Appeals
Customer Service
Blue Cross Complete
1-800-228-8554
P.O. Box 41789
North Charleston, SC 29423 TTY: 1-888-987-5832
Fax: 1-866-900-4482
Healthy Michigan Plan members: For dental appeals, write, call or fax:
Dental Appeals Coordinator
Blue Cross Complete
1-844-320-8465
P.O. Box 2819
9 a.m. to 5 p.m. Monday
through Thursday
Fax: 313-875-2401TTY: 711
Expedited (urgent) review (72 hours): You or your doctor can ask for an
urgent review if waiting the standard review time of 30 days would hurt your
health or life.
If the request for an urgent appeal is granted, we will conduct an urgent
review within 72 hours after we receive your request. If your appeal is not
expedited, Blue Cross Complete will complete a standard review (30 days).
To ask for an urgent review, call Customer Service. You can also fax the
request to us at 1-866-900-4482. You can also ask for an expedited appeal
from the state of Michigan’s Department of Insurance and Financial Services.
We must receive your appeal request within 90 calendar days of the
date you receive the denial notice.
52
53
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
External review
Part 10: Your privacy
Our decision on your appeal is final. If you do not agree with our final
decision, you can ask for an external, or outside, review from the state of
Michigan. The state will conduct this review.
Our commitment to your privacy
Public Act 251 (Patient’s Right to Independent Review Act) describes this
process. There is a time limit. The state needs your request within 60 days of
our denial letter.
Write to:
Department of Insurance and Financial Services
Healthcare Appeals Section
Office of General Council
P. O. Box 30220
Fax: 517-241-4168
We care about your privacy. This section explains how we get and use your
information.
Deliver or overnight to:
611 W. Ottawa, 3rd Floor
We get personal and medical information about you when you enroll in a
health plan. It includes your date of birth, gender and other information. We
also get bills, data about your health care and reports from your doctor.
Call:
This information helps us give you health care coverage. It also helps us
pay provider claims for your care. We will always treat your information as
private. Your information will only be collected and used as explained in our
Notice of Privacy Practices.
1-877-999 6442
This information, along with the forms you need to control who can see your
information, is on our website. You can also ask Customer Service for copies
of this information.
Medicaid fair hearing
You also have the right to a fair hearing with the state of Michigan. Your
doctor or representative could also ask for a hearing. You can do this instead
of or at the same time you send your appeal or complaint to Blue Cross
Complete.
Customer Service
1-800-228-8554
24 hours a day,
seven days a week
You may keep getting benefits while you appeal. However, if your appeal is
not approved, you may have to pay for the benefits you received while your
appeal was reviewed.
You must make your request within 90 days of this letter. Send your request to:
Michigan Administrative Hearing System
Department of Community Health
P.O. Box 30763
Lansing, MI 48909
Or call: 1-877-833-0870
For more information
You have the right at any time to ask for the information we used to make
our decision. This includes the benefit guideline or other criteria. To ask for
more information, write us at:
Member Appeals
Blue Cross Complete
P.O. Box 41789
North Charleston, SC 29423
Healthy Michigan Plan members: For dental appeals information,
write:
Dental Appeals Coordinator
Blue Cross Complete
P.O. Box 2819
Did
you
know?
Generic drugs have the same
active ingredients as the brand
name versions.
54
Learn more about our privacy
practices by reading our
Notice of Privacy Practices in
this section.
55
Your information. Your rights. Our responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
Your rights
You have
the right to:
• Get a copy of your health and
claims records.
• Get a list of those with whom we’ve
shared your information.
• Correct your health and claims records.
• Get a copy of this privacy notice.
• Request confidential communication.
• Choose someone to act for you.
• Ask us to limit the information
we share.
• File a complaint if you believe your
privacy rights have been violated.
Your rights
Get a copy of your
health and claims
records
Ask us to correct
health and claims
records
See page 57 for more information on these rights and how to exercise them.
Request
confidential
communications
Your choices
You have some
choices in the way
that we use and
share information
as we:
• Answer coverage questions from your
family and friends.
• Communicate through mobile and
digital technologies.
• Provide disaster relief.
• Market our services and sell your
information.
Ask us to limit what
we use or share
See page 58 for more information on these rights and how to exercise them.
Get a list of those
with whom we’ve
shared information
Our uses and disclosures
We may use
and share your
information as we:
• Help manage the health care treatment
you receive.
• Do research.
• Run our organization.
• Respond to organ and tissue donation
requests and work with a medical
examiner or funeral director.
• Pay for your health services.
• Administer your health plan.
• Coordinate your care among various
health care providers.
• Help with public health and
safety issues.
• Comply with the law.
• Address worker’s compensation,
law enforcement and other
government requests.
Get a copy of this
privacy notice
Choose someone
to act for you
• Respond to lawsuits and legal actions.
See pages 58, 59 and 60 for more information on these uses and disclosures.
File a complaint
if you feel your
rights are violated
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
• You can ask to see or get a copy of your health and claims records and other health
information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30
days of your request. We may charge a reasonable, cost-based fee.
• You can ask us to correct your health and claims records if you think they are incorrect
or incomplete.
• Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• You can ask us to contact you in a specific way (for example, home or office phone) or to
send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you would be in
danger if we do not.
• You can ask us not to use or share certain health information for treatment, payment or
our operations.
• We are not required to agree to your request, and we may say “no” if it would affect
your care.
• You can ask for a list (accounting) of the times we’ve shared your health information for six
years prior to the date you ask, who we shared it with and why.
• We will include all the disclosures except for those about treatment, payment and health
care operations, and certain other disclosures (such as any you asked us to make).
We’ll provide one accounting a year for free but will charge a reasonable, cost-based
fee if you ask for another one within 12 months.
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive
the notice electronically. We will provide you with a paper copy promptly.
• If you have given someone medical power of attorney or if someone is your legal guardian,
that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
• You can complain if you feel we have violated your rights by contacting us at
1-800-228-8554 or TTY 1-888-987-5832.
• You can file a complaint with the U.S. Department of Health and Human Services Office for
Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201,
calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
56
57
Our Uses and Disclosures (continued)
Your choices
For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described
below, talk to us. Tell us what you want us to do, and we will follow your instructions.
Administer
your plan
• Share information with your family, close friends or others involved in payment for your care.
• Share information in a disaster relief situation.
In these cases, you
have both the right
and choice to tell
us to:
• Share information with you through mobile and digital technologies (such as sending
information to your email address or to your cell phone by text message or through
a mobile app).
If you are not able to tell us your preference, for example if you are unconscious, we may go
ahead and share your information with others (such as to your family or to a disaster relief
organization) if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent threat to health or safety. However, we will not use
Coordinate your
care among
various health
care providers
mobile and digital technologies to send you health information unless you agree to let us do so.
Example: We share health information
information for plan administration.
with others who we contract with for
administrative services.
Our contracts with various programs require
Example: We share health information
that we participate in certain electronic
through an HIN or HIE to provide timely
Health Information Networks (“HINs”) and/
information to providers rendering services
or Health Information Exchanges (“HIEs”)
to you.
so that we are able to more efficiently
coordinate the care you are receiving from
various health care providers.
If you are enrolled/enrolling in a governmentsponsored program, such as Medicaid or
Medicare, please review the information
provided to you by that program to
The use of mobile and digital technologies (such as text message, email or mobile app) has a
number of risks that you should consider. Text messages and emails may be read by a third party
if your mobile or digital device is stolen, hacked or unsecured. Message and data rates may apply.
In these cases we
never share your
information unless
you give us written
permission:
We may disclose your health plan
determine your rights with respect to
participating in an HIN or HIE.
How else can we use or share your health information? We are allowed or required to share your information
in other ways — usually in ways that contribute to the public good, such as public health and research.
We have to meet many conditions in the law before we can share your information for these purposes.
For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
• Marketing purposes.
• Sale of your information.
We can share health information about you for certain situations such as:
Our uses and
disclosures
Help manage
the health care
treatment you
receive
Run our
organization
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
• Preventing disease.
• Helping with product recalls.
• Reporting adverse reactions to medications.
• Reporting suspected abuse, neglect or domestic violence.
We can use your health information and share
Example: A doctor sends us information
it with professionals who are treating you.
about your diagnosis and treatment plan
so we can arrange additional services.
We can use and disclose your information to
Example: We use health information about
run our organization and contact you when
you to develop better services for you.
• Preventing or reducing a serious threat to anyone’s health or safety.
Do research
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it, including with the
Department of Health and Human Services if it wants to see that we’re complying with
federal privacy law.
necessary. We are not allowed to use genetic
information to decide whether we will give
you coverage and the price of that coverage.
This does not apply to long-term care plans.
Pay for your
health services
Help with public
health and safety
issues
We can use and disclose your health
Example: We share information about you to
information as we pay for your health services.
coordinate payment for your health services.
58
Respond to
organ and tissue
donation requests
and work with a
medical examiner
or funeral director
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner or funeral director when
an individual dies.
59
Our Uses and Disclosures (continued)
Changes to the terms of this notice
We can use or share health information about you:
Address workers’
compensation, law
enforcement and
other government
requests
Respond to
lawsuits and
legal actions
Additional
restrictions on use
and disclosure
• For workers’ compensation claims.
• For law enforcement purposes or with a law enforcement official.
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request and on our website, and we will mail a copy to you.
Effective date of this notice: September 3, 2015
• With health oversight agencies for activities authorized by law.
• For special government functions such as military, national security and presidential
protective services.
• We can share health information about you in response to a court or administrative order,
or in response to a subpoena.
• Certain federal and state laws may require greater privacy protections. Where applicable,
we will follow more stringent federal and state privacy laws that relate to uses and
disclosures of health information concerning HIV/AIDS, cancer, mental health, alcohol and/
or substance abuse, genetic testing, sexually transmitted diseases and reproductive health.
Our responsibilities
Blue Cross Complete takes our members’ right to privacy seriously. To provide you with your benefits,
Blue Cross Complete creates and/or receives personal information about your health. This information
comes from you, your physicians, hospitals and other health care services providers. This information,
called protected health information, can be oral, written or electronic.
• We are required by law to maintain the privacy and security of your protected health information.
• We are required by law to ensure that third parties who assist with your treatment, our payment of
claims or health care operations maintain the privacy and security of your protected health information
in the same way that we protect your information.
• We are also required by law to ensure that third parties who assist us with treatment, payment and
operations abide by the instructions outlined in our Business Associate Agreement.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change
your mind.
For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
60
61
Part 11:
Our Board of Managers
Did you know that you can have a say about how Blue Cross Complete
operates? The Blue Cross Complete Board of Managers helps adopt and
put in place the policies that say how Blue Cross Complete runs. The board
meets about four times a year.
It’s important for our members to be represented, so one-third of the board
includes Blue Cross Complete members. Members are elected by other
Blue Cross Complete members to represent them on the board. The board
also includes senior health plan leadership.
Elected members serve on the board for a three-year term. All members
age 21 and older are able to vote for their member board representative.
If you’re interested in being on the board, you must be:
• A current Blue Cross Complete member.
• A Michigan resident.
Certificate
of Coverage
• At least age 21.
• Able to attend board and committee meetings at least four times a
year.
We can help you get rides to the board meetings. If you have questions
about the board or its members, call Customer Service.
1. General conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4. Enrollment requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6. Effective date of coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
7. Blue Cross Complete member rights and responsibilities. . . . . 47
8. Member’s role in policy making. . . . . . . . . . . . . . . . . . . . . . . . . 50
9. Payment for coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
10. Claim provisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
11. Coordination of benefits and subrogation. . . . . . . . . . . . . . . . . 50
12. Out-of-area coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
13. Term and termination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
14. Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
62
63
1. General conditions
Appendix
Part 1: Schedule of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
A-1. Professional services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
1.01This Certificate of Coverage is issued to persons who have enrolled in Blue Cross
Complete through the Michigan Department of Health and Human Services. By enrolling
and accepting this Certificate, the Member agrees to abide by the rules of Blue Cross
Complete as outlined in the Certificate.
1.02
A-2. Hospital services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
A-3. Emergency services and related services . . . . . . . . . . . . . . 58
A-4. Diagnostic and therapeutic services and tests . . . . . . . . . . 59
A-5. Home health services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
A-6. Equipment to support home care. . . . . . . . . . . . . . . . . . . . 60
A-7. Physical, occupational and speech services . . . . . . . . . . . . 60
A-8. Cardiac rehabilitation services. . . . . . . . . . . . . . . . . . . . . . . 60
A-9. Patient counseling and education. . . . . . . . . . . . . . . . . . . . 60
1.03This Certificate of Coverage states the terms of enrollment, membership, and coverage
under which a Medicaid-eligible recipient may secure Blue Cross Complete health
benefits. Appendix A lists the benefits to which these Members are entitled, and specifies
limitations and exclusions.
1.04
GOVERNING LAWS: This Certificate is made and shall be interpreted under the laws of
the state of Michigan.
1.05
WAIVER BY AGENTS: No agent or person, except an authorized officer of Blue Cross
Complete, has authority to waive any conditions or restrictions of this Certificate, or
to bind Blue Cross Complete by making a promise or representation, or by giving or
receiving any information. No change in this Certificate shall be valid unless evidenced by
an endorsement or amendment to it, signed by an authorized officer.
1.06
POLICY AND PROCEDURES: Blue Cross Complete may adopt reasonable policies,
procedures, rules, and interpretations to promote the orderly and efficient administration
of this Certificate.
1.07
ASSIGNMENT: All rights of a Member to receive benefits and services are personal,
granted only to the Member, and may not be assigned to a third party.
1.08
HEADINGS: The headings and captions in this Certificate are not to be considered as part
of the Certificate and are inserted only for convenience.
1.09
NOTICE: Any notice required or permitted to be given by Blue Cross Complete in this
Certificate shall be given in writing and either personally delivered or deposited in the
United States Mail with postage prepaid and addressed to the Member at the address of
record on file at Blue Cross Complete’s administrative offices.
1.10
LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this
policy prior to the expiration of 60 days after written proof of loss has been furnished in
accordance with the requirements of this policy. No such action shall be brought after the
expiration of three years after the time written proof of loss is required to be furnished.
A-10. Skilled nursing facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
A-11. Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
A-12. Hearing examinations and hearing aids . . . . . . . . . . . . . . 61
A-13. Durable medical equipment, prosthetics and orthotics . . 62
A-14. Disposable medical items and other medical supplies. . . 62
A-15. Special provisions applicable to organ and
tissue transplants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
A-16. Health services by nonplan providers. . . . . . . . . . . . . . . . 63
A-17. Mental health services. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
A-18. Oral surgical services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
A-19. Oral health screening and fluoride varnish. . . . . . . . . . . . 64
A-20. Chiropractic services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
A-21. Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
A-22. Podiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
A-23. Prescription drugs and medicine. . . . . . . . . . . . . . . . . . . . 65
Part 2: Schedule of limitations and exclusions . . . . . . . . . . . . . . . . . 66
A-24. Limited and excluded services . . . . . . . . . . . . . . . . . . . . . 66
64
Blue Cross Complete of Michigan is a State approved health maintenance organization
(HMO). Blue Cross Complete of Michigan is an independent licensee of the Blue Cross
Blue Shield Association. The Association permits Blue Cross Complete of Michigan to use
the Blue Cross Blue Shield service mark in Michigan. Blue Cross Complete of Michigan is
not contracting as the agent of the Association. No person, entity or organization other
than Blue Cross Complete will be held accountable or liable to Blue Cross Complete
members for any of Blue Cross Complete’s obligations created under this contract.
Blue Cross Complete is solely responsible for its own debts and other obligations.
2. Definitions
2.01
AMBULATORY SURGERY means surgery performed in an operating room at a hospital or
freestanding surgical center without overnight admission. Procedures routinely performed
in the office of physicians are not considered ambulatory surgery.
2.02
APPROVED FACILITY means a facility that provides medical or other services to Blue Cross
Complete Members and has entered into an agreement with Blue Cross Complete to
do so.
65
2.03
ATTENDING PHYSICIAN means any physician who, upon appropriate referral by a primary
care physician or authorization by Blue Cross Complete, is responsible for the care of Blue
Cross Complete Members in inpatient hospital or ambulatory surgery facilities.
2.04
AUTHORIZED SERVICE means any health care service which is a benefit under the
Certificate and which has been provided or arranged by a primary care physician or his
or her designee and/or authorized by the Blue Cross Complete Medical Director to be
provided by another provider. An authorized service may be referred to in this document
as a covered service.
2.05
BENEFITS are the health care services described in this Certificate of Coverage and
required under Michigan law or by MDHHS.
2.06
BLUE CROSS COMPLETE BEHAVIORAL HEALTH DEPARTMENT is the department that
provides, arranges, or authorizes provision of covered mental health services to Members.
2.07
CERTIFICATE OF COVERAGE (or Certificate) is the statement of covered benefits,
including the terms of enrollment and covered services. Certificate of Coverage may also
be referred to as the Certificate.
2.08
• Serious jeopardy to the health of the individual or in the case of a pregnant woman, the
health of the woman or her unborn child,
• Serious impairment to bodily functions, or
• Serious dysfunction of any bodily organ or part.
Further, emergency services means covered inpatient and outpatient services that are as
follows:
• Furnished by a provider that is qualified to furnish these services under this title.
• Needed to evaluate or stabilize an emergency medical condition.
Poststabilization care services means covered services, related to an emergency medical
condition that are provided after a Member is stabilized in order to maintain the stabilized
condition, or, to improve or resolve the enrollee’s condition.
2.18
ENROLLEE is an individual determined by MDHHS to be entitled to receive health care
services under this Certificate of Coverage.
2.19
EXPERIMENTAL, INVESTIGATIONAL OR RESEARCH MEDICAL, SURGICAL CARE DRUG,
DEVICE, TREATMENT, OR PROCEDURE
CONTRACT consists of the Blue Cross Complete Health Plan Certificate of Coverage
including General Conditions, Definitions, Limitations and Exclusions, the issued member
ID cards, forms and questionnaires completed by the Member, and any duly authorized
amendments, riders, or endorsements.
2.09
CONTRACT YEAR means the 12-month period beginning with the effective date of the
contract between MDHHS and Blue Cross Complete.
2.10
CONTRACTED HOSPITAL means a hospital which has signed a contract with Blue Cross
Complete or on whose behalf a contract has been signed to provide covered services
to Blue Cross Complete Members in accordance with the terms and conditions of the
contract. A contracted hospital also may be referred to as a participating hospital or a
network hospital.
2.11
CONTRACTED PHYSICIAN means a physician who has signed a contract with Blue
Cross Complete or on whose behalf a contract has been signed or who is employed by a
contracted hospital or who is a participant in a physician group or PHO which has signed a
contract to provide covered services to Blue Cross Complete Members in accordance with
the terms and conditions of the contract. A contracted physician also may be referred to as
a participating physician or a network physician.
2.12
CONTRACTED PROVIDER means a provider who has signed a contract with Blue Cross
Complete or on whose behalf a contract has been signed to provide covered services
to Blue Cross Complete Members in accordance with the terms and conditions of the
contract. A contracted provider also may be referred to as a participating provider.
2.13
COVERED SERVICE(S) means the comprehensive health care services delivered under the
terms and conditions for their delivery described in the Certificate of Coverage.
2.14
CUSTODIAL CARE is provided by persons without professional health care skills or
training, primarily for the purpose of meeting personal needs such as bathing, walking,
dressing, and eating.
2.15
DURABLE MEDICAL EQUIPMENT is equipment that is able to withstand repeated use, is
customarily used to serve a medical purpose, and is not useful to a person in the absence
of illness or injury. Examples include canes, crutches, and bed rails.
2.16
EFFECTIVE DATE is the date the Member is entitled to receive covered services pursuant
to this Contract as determined by MDHHS.
2.17
EMERGENCY SERVICES means medically necessary services provided to a Member for the
sudden onset of a medical condition that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the absence of immediate medical attention
could reasonably be expected to result in:
66
This means a drug, device, treatment, or procedure meeting one or more of the following
criteria:
• It cannot be lawfully marketed, without the approval of the U.S. Food and Drug
Administration and such approval has not been granted at the time of its use or
proposed use; or
• It is the subject of a current investigational new drug or new device application on file
with the FDA; or
• It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental
or research arm of a Phase III clinical trial; or
• It is being provided pursuant to a written protocol which describes among its objectives
the determination of safety, efficacy or efficiency in comparison to conventional
alternatives; or
• It is described as experimental, investigational or research by informed consent or
patient information documents; or
• It is being delivered or should be delivered subject to the approval and supervision
of an Institutional Review Board (IRB) as required and defined by federal regulations,
particularly those of the FDA or the Department of Health and Human Services (HHS) or
successor agencies, or of a human subjects (or comparable) committee; or
• The predominant opinion among experts as expressed in the published authoritative
medical investigational or research settings; or
• The predominant opinion among experts as expressed in the published authoritative
medical or scientific literature is that further experiment, investigation or research is
necessary in order to define safety, toxicity, effectiveness or efficiency compared with
conventional alternatives.
(Antineoplastic drug therapy shall be provided in accordance with Michigan law.)
2.20
FEE SCHEDULE means the schedule of fees that Blue Cross Complete pays to contracted
providers for services and benefits under this Certificate.
2.21
HEARING AID is an electronic device worn for the purpose of amplifying sound and
assisting the physiological process of hearing.
2.22
HOMEBOUND means a medical condition that prevents the patient from leaving home.
2.23
HOME HEALTH AGENCY is an organization licensed or certified pursuant to the laws of
the state of Michigan as a home health agency and which has entered into an agreement
with Blue Cross Complete to provide covered services to Members.
67
2.24
HOME HEALTH CARE means part-time skilled health care provided for homebound
Members in the home for the treatment of an illness or injury, for medical conditions which
are not long-term or chronic in nature.
2.25
HOSPICE CARE means services that are primarily used to provide pain relief, symptom
management, and supportive services to the terminally ill and their families.
2.26
Blue Cross Complete of Michigan is authorized by the state of Michigan to arrange for the
provision of health care services as a health maintenance organization (HMO).
2.27
Blue Cross Complete of Michigan is the name of the health care plan described in this
Certificate of Coverage. Blue Cross Complete of Michigan may be referred to in this
document as Blue Cross Complete, Plan, Health Plan or as the Medicaid Plan.
2.28
MEDICAID FAIR HEARING PROCESS means a process that exists at the Michigan
Department of Health and Human Services that a Member may use to raise any concerns
about any Blue Cross Complete decision under this Certificate. The Medicaid Fair Hearing
Process is described in the Member Handbook.
2.29
MEDICAL DIRECTOR is a Michigan licensed physician designated by Blue Cross Complete
to provide medical management and related services on behalf of Blue Cross Complete.
As used in the Certificate, the term shall include any individual designated by the Medical
Director to act on his or her behalf.
2.30
MEDICALLY NECESSARY means services and supplies furnished to a Member when and
to the extent the Blue Cross Complete Medical Director or his or her designee determines
that they satisfy all of the following criteria:
• They are medically required and medically appropriate for the diagnosis and treatment
of the Member’s illness or injury;
• They are consistent with professionally-recognized standards of health care;
• They do not involve costs that are excessive in comparison with alternative services that
would be effective for the diagnosis and treatment of the Member’s illness or injury.
The fact that a physician may have prescribed, ordered, recommended, or approved the
provision of certain services to the Member does not necessarily mean that such services
satisfy the above criteria.
2.31
MEMBER means an individual entitled to receive benefits under this Certificate.
2.32
MEMBER APPEALS PROGRAM (MAP) means the process under which a Member
may obtain a response to a concern about Blue Cross Complete, the Plan, and/or any
physicians, health professionals, or other affiliated providers who have provided service to
the Blue Cross Complete Member. The MAP provides for a response in accordance with
established procedures described in the Member Handbook.
2.33
NONAUTHORIZED SERVICE means any health care service, whether or not a benefit
under this Certificate, which has not been provided or arranged by the primary care
physician or his or her designee, or has not been authorized by Blue Cross Complete to be
provided by another provider.
2.38
PRESCRIPTION means any physician or licensed practitioner order for a medicinal
substance which under the Federal Food, Drug, and Cosmetic Act is required to bear on
the packaging label the following legend: “Caution: Federal Law prohibits dispensing
without a prescription.”
2.39
PRIMARY CARE PHYSICIAN (PCP) means the contracted physician who is primarily
responsible for providing or coordinating the provision of health services to a Member
through referrals to other health care professionals, facilities, or entities. A primary care
physician’s specialty is Family Practice, General Practice, Internal Medicine, OB-GYN, or
Pediatrics. A specialist may act as a PCP when the Enrollee’s medical condition warrants
management by a physician specialist when approved by Blue Cross Complete.
2.40
PROSTHETIC DEVICE is a device which aids body functioning or replaces a limb or body
part.
2.41
RESTORATIVE HEALTH SERVICES means intermittent or short-term rehabilitative nursing
care that may be provided in or out of a health care facility.
2.42
SERVICE AGREEMENT is the contract between Blue Cross Complete of Michigan and the
Michigan Department of Management and Budget, Acquisition Services, which establishes
the scope of benefits being purchased, the criteria for eligibility, as well as the underwriting
and administrative agreements between the parties.
2.43
SERVICE AREA means the geographical area in which Blue Cross Complete has been
authorized by state authorities to provide or arrange for the provision of health services to
Members by network providers.
2.44
SKILLED CARE is service, furnished on physician orders, that requires the skills of qualified
technical or professional health personnel. Some of these are defined as: registered
nurses, physical therapists, occupational therapists, and speech pathologists. The care
must be provided directly by, or under the general supervision of, these skilled nursing
or skilled rehabilitation personnel to assure the safety of the Member, and to achieve the
medically desired result.
2.45
SKILLED NURSING FACILITY is an institution which has been licensed by the state of
Michigan and certified by Medicaid to provide skilled care nursing services.
2.46
SPECIALIST is a physician to whom a Blue Cross Complete Member has been referred by
the Blue Cross Complete primary care physician or his or her designee and/or Blue Cross
Complete for special consultation or treatment.
3. Eligibility
3.01
3.02
MEMBERS – To be eligible to enroll, a person must:
• Be eligible for Medicaid as determined by MDHHS,
• Have a Medicaid status that is permitted by MDHHS to enroll in an HMO, and
• Reside within the service area.
In all cases, final determination of Blue Cross Complete eligibility is made by MDHHS.
2.34
NONCOVERED SERVICE means any health care service excluded as a benefit under this
Certificate.
2.35
NONPLAN PROVIDER means any health care professional or provider who is not party to a
contract with Blue Cross Complete to provide services to Medicaid members.
4.01
The categories of Medicaid-eligible persons who may enroll in HMOs are determined by
MDHHS.
2.36
ORTHOTIC DEVICE is an external device which is designed to correct or assist in the
prevention of a bodily defect either of form or function.
4.02
2.37
PLAN means the Blue Cross Complete Medicaid Plan.
Newborns of Medicaid-eligible women are automatically enrolled in Blue Cross Complete
effective with date of birth if the mother is a Blue Cross Complete Member at the time
of delivery.
68
4. Enrollment requirements
69
5. Disenrollment
5.01
If a Member wishes to disenroll, he/she must follow the procedures set forth by MDHHS.
Disenrollment information is available upon request from the Customer Service department.
5.02
All rights to benefits cease as of the effective date of disenrollment, without prejudice to
claims for services rendered prior to the effective date of disenrollment. However, if the
Member is an inpatient of an acute care facility at the time of disenrollment, Blue Cross
Complete will cover the stay until the day of discharge. The disenrollment date will be
determined by MDHHS.
5.03
Blue Cross Complete may request special disenrollment of a Member from the Michigan
Department of Health and Human Services if a Member’s actions are inconsistent with
Blue Cross Complete membership. Disenrollment for an approved request will be effective
immediately. Special disenrollment requests may be made in cases of:
• Violent/life-threatening situations involving physical acts of violence; physical or verbal
threats of violence made against Blue Cross Complete-affiliated providers, Blue Cross
Complete staff or the public at Blue Cross Complete locations; or where stalking
situations exist; or
• Fraud/misrepresentation to the plan, including alteration or theft of prescriptions or
misrepresentation of Blue Cross Complete membership allowing another person to
receive health care services or allowing another person use of member’s ID card; or
• Other noncompliance situations including repeated use of non-Blue Cross Completeaffiliated providers; discharge from the practices of multiple Blue Cross Complete
network providers; repeated emergency room use; and those who impede care.
Special disenrollments will occur only to the extent consistent with the rules and
regulations of MDHHS.
5.04
• Request and receive:
– The Blue Cross Complete Provider Directory
– The professional education of your providers, including those who are board
certified in the specialty of pain medicine for evaluation and treatment
– The names of hospitals where your physicians are able to treat you
– The contact information for the state agency that oversees complaints or corrective
actions against a provider
– Any authorization, requirements, restrictions or exclusions by service, benefit or a
specific drug
– The information about the financial agreements between Blue Cross Complete and
a participating provider
Member responsibilities:
• Know your Blue Cross Complete Certificate
• Know your Member Handbook and all other provided materials
• Call Customer Service with any questions
• Seek services for all nonemergency care through your primary care physician, except as
otherwise stated in this Certificate
• Use the Blue Cross Complete network
• Be referred and approved by Blue Cross Complete and your primary care physician for
out-of-network services
• Make and keep appointments with your primary care physician
• Contact your doctor’s office if you need to cancel an appointment
• Be involved in decisions regarding your health
• Behave in a proper and considerate manner to providers, their staff, other patients and
Blue Cross Complete staff
• Tell Blue Cross Complete of address changes, any changes for your dependents
coverage and any other health coverage
• Protect your card against misuse
• Call Customer Service right away if your card is lost or stolen
• Follow your doctor’s instructions regarding your care
• Make treatment goals with your physician
• Contact Blue Cross Complete Anti-fraud Unit if you suspect fraud
For more information, members may contact Customer Service.
6. Effective date of coverage
6.01
All eligible, enrolled Members will be covered under this Certificate on the date agreed
upon between MDHHS and Blue Cross Complete.
7. Blue Cross Complete Member rights and responsibilities
7.01
RIGHTS AND RESPONSIBILITIES
Member rights will be honored by all Blue Cross Complete staff and affiliated providers.
Member rights:
• Understand information about your health care
• Get required care as described in this book
• Be treated with dignity and respect
• Privacy of your health care information, as outlined in this handbook
• Treatment choices, in spite of cost or benefit coverage
• Fully join in making decisions about your health care
• Refuse to accept treatment
• Voice complaints, grievance or appeals about Blue Cross Complete and its services,
benefits, providers and care
• Get clear and easy to understand written information about Blue Cross Complete’s
services, practitioners, providers, rights and responsibilities policies
• Review your medical records and ask that they be corrected or amended
• Make suggestions regarding Blue Cross Complete’s rights and responsibilities policies
• Be free from any form of abuse, being restrained or secluded, as a means of coercion,
discipline, convenience or retaliation when receiving services
70
7.02
PRIMARY CARE PHYSICIAN SELECTION AND CONTINUITY OF CARE
Upon enrollment, and by the effective date thereof, the Member shall select a primary
care physician for each member of the family. Blue Cross Complete reserves the right to
choose a primary care physician for the Member in the event that he/she does not indicate
a physician selection. Blue Cross Complete will use prescribed guidelines to make such a
selection.
Adult members may change their primary care physician or that of their enrolled child
by submitting a request to Blue Cross Complete. Foster parents must contact the child’s
MDHHS case worker to change the child’s primary care physician. Normally, such a change
will take effect within two business days after BCC receives the request. Blue Cross Complete
may limit the number of times a member can change PCPs without cause in a year.
If a member’s PCP leaves Blue Cross Complete’s network for any reason other than failure
to meet Blue Cross Complete’s quality standards or fraud, a Member who is undergoing an
71
ongoing course of treatment with that physician may be eligible to receive treatment from
that physician as follows:
• For as many as ninety (90) days after the Member receives notice that the contracted
physician is leaving Blue Cross Complete’s network.
• If the Member is in her second or third trimester of pregnancy at the time of her
obstetrician’s termination from the Blue Cross Complete network, she may continue with
the terminated physician through post-partum care (i.e., the regular post-partum visit)
directly related to that pregnancy.
• If the Member is determined to have a terminal illness prior to a physician’s termination
or knowledge of the termination and the physician was treating the terminal illness
before the date of termination or knowledge of termination, for the remainder of the
Member’s life for care directly related to the treatment of the terminal illness. All other
care must be provided by contracted providers.
Except as otherwise stated in this Certificate, continuity of care applies only if the requested
continuation is prior authorized by Blue Cross Complete and the departing physician agrees to
all of the following: (i) to continue to accept as payment in full reimbursement from Blue Cross
Complete at the rates applicable before the termination; (ii) to follow Blue Cross Complete’s
standards for maintaining quality health care and to provide to Blue Cross Complete medical
information related to the care; and (iii) to otherwise comply with Blue Cross Complete’s
policies and procedures including, but not limited to, those concerning utilization review,
referrals, prior authorization, and treatment plans.
7.03
7.04
REFUSAL TO ACCEPT TREATMENT/NONCOMPLIANCE WITH TREATMENT PLAN
A Member enrolls in Blue Cross Complete with the understanding that providers are
responsible for determining treatment appropriate to the Member’s care. A Member may
refuse procedures recommended by a physician. If refusal of recommended procedure
is related to lack of agreement between the physician and patient and creates a barrier
to the delivery of proper health care, the health plan may assist the member in changing
the primary care physician. If the Member refuses to accept recommended treatment or
procedures and no alternatives exist, the Member shall be so advised.
MEMBER APPEALS PROGRAM
Blue Cross Complete has set up a mechanism for receiving, processing, and resolving
Member appeals and grievances relating to the benefits or the operation of Blue Cross
Complete. This is fully described in the Blue Cross Complete Medicaid Plan Member
Handbook, “Part 8: If you have a concern.” Members will receive a copy of the Member
Handbook describing the Member Appeals Program when they enroll with Blue Cross
Complete, and may receive additional copies at any time by telephone request to
Customer Service at the number listed below.
There is a time limit on filing an appeal. You must file within 90 days of the problem or
denial. Contact us for a form to do this. If you have questions please call Customer Service at
1-800-228-8554 (TTY: 1-800-649-3777). You may also make an appointment to come into
Blue Cross Complete’s office.
7.05
MEMBER IDENTIFICATION CARDS
Mere possession of the Blue Cross Complete Member Identification Card confers no right
for benefits under this Certificate. To be entitled to such benefits, the holder of the card
must meet and maintain all MDHHS requirements.
If a member permits the use of his or her Member Identification Card by any other person,
the card may be reclaimed by Blue Cross Complete and/or its providers, and all rights of
such Member and other members of his or her family can be terminated immediately (see
Section 13.02). A Member shall report loss or theft of the Member Identification Card to
Blue Cross Complete immediately upon discovery of loss or theft.
72
7.06
FORMS AND QUESTIONNAIRES
Members shall complete and submit to Blue Cross Complete such forms and medical
questionnaires as requested. Members warrant that all information completed by them is
true, correct, and complete to the best of their knowledge.
7.07
BENEFITS, POLICIES, AND PROCEDURES
The Member is responsible for becoming familiar with and following Blue Cross Complete
Medicaid Plan benefits, policies, and procedures.
7.08
HEALTH MANAGEMENT PROGRAM
Enrolling in Blue Cross Complete entitles the Member to participate in Blue Cross
Complete’s Health Management Program which includes health promotion activities, health
education activities, disease management programs, and case management programs.
7.09
MEMBERSHIP RECORDS
Blue Cross Complete will keep membership records. Blue Cross Complete is not liable
for any obligation dependent upon information to be supplied by the Member prior to
receipt in satisfactory form. Incorrect information furnished may be corrected if Blue Cross
Complete has not acted to its prejudice by relying on it.
7.10
AUTHORIZATION TO RECEIVE INFORMATION
Blue Cross Complete is entitled to receive from any provider of services to Members
information reasonably necessary in connection with the administration of this Certificate
but subject to applicable confidentiality requirements. By acceptance of coverage under
this Certificate, the Member authorizes providers rendering services hereunder to report
to and disclose information concerning the care, treatment and physical condition of the
Member to Blue Cross Complete upon request and to permit copying of records by Blue
Cross Complete.
8. Member’s role in policy making
8.01
BOARD OF MANAGERS
As provided by law, at least one third of the Blue Cross Complete Board of Managers
shall consist of adult enrollees elected by persons enrolled in Blue Cross Complete. Each
Member shall receive a list of Blue Cross Complete’s Board of Managers with enrollee
board members clearly identified. Changes in Board membership shall be reflected in Blue
Cross Complete’s periodic newsletter. Members may contact Blue Cross Complete or the
enrollee representatives for information on becoming a member of the Board of Managers.
8.02
REGULAR COMMUNICATION
Members shall receive Blue Cross Complete’s newsletter which will provide information
regarding current policy, policy changes, and how best to take advantage of the Blue
Cross Complete Plan services.
9. Payment for coverage
9.01
MDHHS is responsible for making premium payments to Blue Cross Complete for
all Medicaid members. Payments shall be made in accordance with the terms of the
agreement between Blue Cross Complete and MDHHS.
10. Claim provisions
10.01
It is not expected that a Member will make payments to any participating provider for
benefits under this Certificate. However, if the Member furnishes evidence satisfactory to
Blue Cross Complete that he/she has made payment to a contracted authorized provider
in exchange for benefits provided under this Certificate, and that the payment is the
responsibility of Blue Cross Complete, the Member shall be reimbursed by Blue Cross
Complete, so long as an itemized bill and original evidence of payment (canceled check,
73
In the event a suit instituted by Blue Cross Complete on behalf of the Member results in
monetary damages awarded in excess of the cash value of actual benefits provided by
Blue Cross Complete, Blue Cross Complete shall have the right to recover costs of suit and
attorney fees out of the excess, to the extent of the cost of such fees.
cash receipt, etc.) is received by Blue Cross Complete no later than one year from the date
of service. Receipts may be submitted to:
Blue Cross Complete
Attention: Claims
P.O. Box 7355
London, KY 40742
11.04
RIGHT OF PAYMENT AND RECOVERY
Whenever benefits have been provided by Blue Cross Complete under the contract and
the responsibility for payment is with another plan, Blue Cross Complete shall have the
right to deny payment or recover from the other plan the reasonable cash value of each
service provided by Blue Cross Complete in a total amount necessary to satisfy the intent
of this section.
11.05
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
For the purpose of determining the applicability of and implementing the terms of this
section, Blue Cross Complete will be required from time to time to release or to obtain
information with respect to a Member, which it deems to be necessary for such purposes.
A Member who is claiming benefits under the contract shall furnish to Blue Cross
Complete such information as may be necessary to implement this section. This would
include notifying Blue Cross Complete if there is any change in other insurance coverage.
11. Coordination of benefits and subrogation
Other party liability
Blue Cross Complete does not pay claims or coordinate benefits for services which are not
provided or authorized by a Blue Cross Complete physician and which are not benefits
under this Certificate, except as otherwise stated in this Certificate.
11.01
GENERAL PROVISION
Blue Cross Complete intends to provide each of its Members with full benefits to the limit
of this Certificate. However, a Member may not receive duplicate benefits, or benefits
greater than the actual expenses incurred or Blue Cross Complete’s fee schedule amount,
whichever is less. Duplicate coverage does not extend available Blue Cross Complete
benefits beyond the limits of this Certificate.
The Member shall execute and deliver such instruments and take such other action as Blue
Cross Complete may require implementing the provisions of this section. The Member
shall do nothing to prejudice the rights given Blue Cross Complete by this provision
without its prior written consent.
Benefits are not provided under this Certificate to the extent that any amounts are paid or
payable for expenses to or on behalf of the Member under the provisions of any insurance,
service benefit or reimbursement plan providing similar direct benefits without regard to
fault, including by way of illustration and not limitation: Medicare, Worker’s Compensation,
Employer’s Liability Law, or No Fault Automobile Insurance.
11.02
COORDINATION OF BENEFITS
If a Blue Cross Complete Member is injured and requires treatment relating to a motor
vehicle accident, Blue Cross Complete will require a statement indicating the type of
medical coverage carried on the Member’s automobile insurance.
In establishing the order of carrier responsibility applicable to health plans covering Blue
Cross Complete Members, Blue Cross Complete will follow the coordination of benefits
guidelines of MDHHS.
All medical bills must first be submitted to the primary insurance carrier. Blue Cross
Complete will generally be the payer of last resort.
11.03SUBROGATION
If the Member has a right of recovery from person or organization for any benefits or
supplies covered under this contract (except from a Member’s health insurance coverage,
subject to the coordination of benefits provisions), the Member, as a condition to receiving
benefits under this contract, will either:
• Pay Blue Cross Complete all sums recovered by suit, settlement, or otherwise, to the
extent of benefits provided by Blue Cross Complete and in an amount equal to the Blue
Cross Complete payment for those benefits, but not in excess of monetary damages
collected; or,
• Authorize Blue Cross Complete to be subrogated to the Member’s rights of recovery, to
the extent only of the benefits provided including the right to bring suit in the Member’s
name at the sole cost and expense of Blue Cross Complete.
74
12. Out-of-area coverage
12.01 Members are entitled to out-of-area coverage for urgent and emergent medical care.
Routine out-of-area care must be requested in advance by the primary care physician and
approved in writing in advance by Blue Cross Complete. Services authorized by Blue Cross
Complete to be received outside the state of Michigan will be administered consistent
with the requirements of MDHHS and through BlueCard, a Blue Cross Blue Shield
Association Program. For more information, please call Customer Service.
13. Term and termination
13.01TERM
This Certificate shall continue in effect from the effective date as long as the Member is
eligible according to MDHHS and as long as Blue Cross Complete is contracted with the
state of Michigan as a qualified health plan for the Medicaid program.
13.02
TERMINATION FOR CAUSE
Coverage for a Member may be terminated for cause, subject to reasonable notice and
the consent of MDHHS for:
• Violent/Life-Threatening situations including physical acts of violence; physical or verbal
threats of violence made against Blue Cross Complete-affiliated providers, Blue Cross
Complete staff, or the public at Blue Cross Complete locations; or where stalking
situations exist; or
• Fraud/Misrepresentation including alteration or theft of prescriptions or
misrepresentation of Blue Cross Complete membership allowing another person to
receive health care services or allowing another person use of member’s ID card; or.
• Other noncompliance situations including repeated use of non-Blue Cross Completeaffiliated providers; discharge from the practices of multiple Blue Cross Complete
network providers; repeated emergency room use; and those who impede care.
NOTE: On or after the effective date of termination for cause, premium payments received
on behalf of such terminated Member for periods following the termination date shall be
refunded to MDHHS. Blue Cross Complete shall however, make reasonable attempts to
transfer care of patients terminated from the Plan to other providers.
75
13.03
LOSS OF ELIGIBILITY
Blue Cross Complete will request disenrollment of Member from MDHHS if the Member is
no longer eligible for coverage under the contract as specified in Section 3, Eligibility.
13.04
CESSATION OF OPERATIONS
In the event of cessation of operations or dissolution of Blue Cross Complete, this
Certificate may be terminated immediately by order of proper authority. Blue Cross
Complete may be obligated for services as prescribed by law or proper order.
14. Benefits
14.01
Members are entitled to receive the services described herein in accordance with all
terms and conditions of this Certificate. Blue Cross Complete primary care physicians are
responsible for providing or arranging for care to Blue Cross Complete Members, except
as otherwise stated in this Certificate.
When necessary, the Member’s primary care physician will refer a Member for care to a
specialist. Usually, the specialist will also participate with Blue Cross Complete. Blue Cross
Complete shall have no liability or obligation for any benefits received by Members from
any other physician, hospital or organization unless requested in advance by the primary
care physician or prior authorized by Blue Cross Complete, except as otherwise stated in
this Certificate.
Certain exceptions apply (e.g., emergency services, routine obstetrical and gynecological
services). If you have not chosen a Blue Cross Complete pediatrician to be your child’s PCP
and want to take your child to a Blue Cross Complete pediatrician for general pediatric
services, you can do so without a referral. Blue Cross Complete may re-assign that
pediatrician to be your child’s PCP.
You don’t pay for services covered by Blue Cross Complete, as long as they are medically
necessary and arranged by your PCP. The following is a list of those services, which are
also listed in the Handbook:
• Blood lead testing for members under age 21
• Breast cancer services – services to treat breast cancer as required by federal and state
women’s health and cancer protection acts, including diagnostic, outpatient treatment
and rehabilitative services
• Chiropractic services
• Diagnostic laboratory, X-ray and other imaging services
• Doctor office visits
• Emergent and urgent care services
• Family-planning services
• Health education – disease management programs
• Hearing examinations for all members and hearing aids for members under age 21
• Home health services and skilled nursing home services, when medically necessary
(You can use these after you leave the hospital or instead of going to the hospital. Your
primary care physician will help you arrange these services.)
• Hospice services (if you request)
• Hospital services requiring an overnight stay
These include:
– Cost of a semi-private room (sharing a room with one other person)
– Intensive care nursing services – Doctor services
– Surgical services
– Anesthesia (medication to relax or put you to sleep before surgery)
–X-rays
– Laboratory services
• Medical equipment and supplies, durable
• Mental health services – short term, up to 20 outpatient visits per year
• Midwife services – when provided by a certified nurse midwife
• Nurse practitioner services – when provided by a certified pediatric or family nurse
• Out-of-network services – when authorized by Blue Cross Complete, except as otherwise
stated in this Certificate
• Parenting and birthing classes
• Physical exams – routine or annual physical exams
• Podiatric (foot specialist) services, when medically necessary
• Practitioner services – such as those provided by physicians and specialists
• Pregnancy care – including prenatal and postpartum care (before and after birth)
• Prescriptions and pharmacy services
• Prosthetics and orthotics
• Rehabilitative or restorative services – intermittent or short term, in a nursing facility for
up to 45 days
• Rehabilitative or restorative services in a place of service other than a nursing facility
• Renal disease services – end stage
• Sexually transmitted disease treatment
• Smoking and tobacco cessation treatment, including drugs and behavioral support
(tobacco quit program)
• Specialist visits
• Surgical services – not requiring an overnight hospital stay
• Therapy – physical, speech and language, occupational
• Transplant services
• Transportation – by ambulance and other emergency medical transport
• Transportation – to nonemergency covered medical services
• Vaccinations (Covered vaccinations do not require prior authorization if provided by local
health departments.)
• Vision – routine services
• Weight-reduction services – if medically necessary
• Well-baby and well-child care – Early Periodic Screening Diagnosis and Treatment
Program for persons under age 21
Your primary care physician can help you get the Blue Cross Complete services you need. Customer
Service can also answer questions about your benefits.
76
77
Appendix A
Part 1: Schedule of Benefits
Coverage under this Certificate is available for only those services and benefits provided
or arranged by the primary care physician and authorized as necessary by Blue Cross
Complete. Certain exceptions apply (e.g., emergency services and routine obstetrical and
gynecological services). Only services that are medically necessary according to generally
accepted standards of practice as determined by the Blue Cross Complete Medical
Director or his or her designee are considered benefits under this Certificate. Blue Cross
Complete will only pay for covered services.
A-1. Professional services
GENERAL CONDITIONS
Physician and consultation services provided or arranged by the primary care physician are
covered under this section. Certain exceptions apply; (see emergency services and routine
obstetrical and gynecological services). Covered professional services include:
A-1.01 Office visits provided by the Member’s primary care physician or a specialist to whom a
Member is referred by the primary care physician.
A-1.02 Routine and periodic age/gender specific examinations by the Member’s primary care
physician.
A-1.03 Women have open access to contracted obstetricians and gynecologists for annual, wellwoman exams and other routine gynecological and obstetrical services. If routine services
identify a need for ongoing care, a Member must obtain a referral from her primary care
physician prior to seeking ongoing services from a specialist.
A-1.04 Pediatric care including well-child care, diagnosis and treatment of illness and injury, and
services provided by the Early and Periodic Screening Diagnosis and Treatment Program
(EPSDT) as defined by MDHHS.
A well-child examination may include:
•
•
•
•
•
•
•
•
•
•
A health and developmental history
A developmental and behavioral assessment
Age-appropriate physical examination
Height and weight measurements and age-appropriate head circumference
Blood pressure testing for children aged 3 and older
Immunization review and administration of appropriate immunizations
Health education including anticipatory guidance
Nutritional assessment
Hearing, vision, and dental assessments
Lead toxicity screening for children ages 1 to 5, with blood sample testing for lead levels
as indicated, and all related follow-up services
• Tuberculin testing and related laboratory services
• An interpretive conference and appropriate counseling for parents/guardians
The following EPSDT program services are also covered:
• Diagnosis and treatment for defective vision, including glasses
• Relief of dental pain and infections, restoration of teeth and maintenance of
dental health
• Diagnosis and treatment for hearing defects, including hearing aids
• Health care, diagnosis, treatment or other services to correct or improve defects,
physical or mental illnesses and conditions discovered during a screening
78
If you have not chosen a Blue Cross Complete pediatrician to be your child’s PCP and want
to take your child to a Blue Cross Complete pediatrician for general pediatric services,
including well-child care, you can do so without a referral. Blue Cross Complete may
re-assign that pediatrician to be your child’s PCP.
A-1.05 Pediatric and adult immunizations in accordance with accepted medical practice.
A-1.06 Surgery during inpatient hospital admission or ambulatory surgery as provided or arranged
for by the primary care physician or specialist.
A-1.07 Hospital visits as part of the continued supervision of covered care.
A-1.08 Physician or health professional services including those of anesthesiologists, pathologists,
radiologists, and other medical specialists as may be required.
A-1.09 Services for diagnostic evaluation and assessment of infertility are covered, but limited
to techniques and procedures approved by Blue Cross Complete. In-vitro fertilization,
artificial insemination, intrauterine insemination, reversal of voluntary sterilization, and
treatment for infertility are excluded.
A-1.10 Family planning services such as contraception counseling and associated physical exams
and procedures are covered. Contraceptive devices/drugs are covered. Condoms may be
obtained 12 at a time (36 per month maximum) from a family planning services provider or
contracted pharmacy. Members may self-refer to family planning clinics for family planning
services.
A-1.11 Adult sterilization procedures when performed by a Blue Cross Complete participating
provider. Primary care physician referral is required. Sterilization reversals are excluded.
A-1.12 Abortion is covered if medically necessary to save the life of the mother. Elective abortions
are not covered unless the pregnancy is the result of rape or incest, and requires referral
by the primary care physician. Treatment for medical complications occurring as a result
of an elective abortion is covered. Treatment for spontaneous, incomplete or threatened
abortions and for ectopic pregnancies is covered.
A-1.13 Physician services for prenatal and postpartum care are covered. Members may self-refer
to a Blue Cross Complete-contracted obstetrical provider or obstetrician/gynecologist
(OB-GYN) for routine obstetrical services. Routine obstetrical services include prenatal care
and related obstetric services for uncomplicated (low-risk) pregnancies. During pregnancy,
travel restrictions may apply to coverage of deliveries at the discretion of the physician or
approved Plan obstetrician/gynecologist.
A-1.14 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act
Under federal law, health insurance issuers such as Blue Cross Complete generally may
not restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96
hours following a delivery by cesarean section. However, Blue Cross Complete may pay
for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician
assistant), after consultation with the mother, discharges the mother or newborn earlier.
In addition, under federal law, issuers may not set the level of benefits or out-of-pocket
costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less
favorable to the mother or newborn than any earlier portion of the stay.
In addition, an issuer may not, under federal law, require that a physician or other health
care provider obtain authorization for prescribing a length of stay of up to 48 hours (or
96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket
costs, you may be required to obtain precertification. For information on precertification,
contact Blue Cross Complete.
A-1.15 RECONSTRUCTIVE SURGERY/PROCEDURES
Reconstructive surgery is performed on the body in order to improve/restore
bodily function or correct deformities resulting from disease, trauma, congenital or
79
developmental anomalies or previous therapeutic processes. Any such procedures must be
recommended by the Member’s primary care physician and prior authorized by Blue Cross
Complete in order to be covered benefits, except as otherwise stated in this Certificate.
Blue Cross Complete provides coverage for established, medical necessary diagnostic,
outpatient treatment and rehabilitative services to diagnose and treat breast cancer, as
well as the below listed services following a medically necessary mastectomy:
•
•
•
•
Reconstruction of the breast;
Surgery on the other breast to achieve the appearance of symmetry;
Prostheses; and
Treatment of physical complications during any stage of the mastectomy, including
lymphedemas.
A-2. Hospital services
Inpatient hospital services and ambulatory surgery are covered services when:
• Admission is ordered by the primary care physician and authorized by Blue Cross
Complete; and
• Admission occurs on or after the effective date of this Certificate.
A-2.01 Room and board in a semi-private room.
A-2.02 Private room accommodations only when deemed medically necessary by the Member’s
attending physician.
A-2.03 All covered services deemed medically necessary by the attending physician.
A-2.04 Delivery and postpartum care.
A-2.05 Use of special care units, including specialized intensive and coronary care units, when
deemed medically necessary; and operating or other surgical treatment rooms.
A-2.06 Anesthesia, laboratory, and pathology services.
A-2.07 Chemotherapy, antineoplastic drug therapy as required by Michigan law, and
hemodialysis.
A-2.08 Diagnostic tests performed in the hospital in conjunction with the Member’s ambulatory
surgery or admission to the hospital.
A-2.09 Oxygen and gas therapy, drugs and biological solutions, medical and surgical supplies and
equipment, and radioisotopes while in the hospital.
A-2.10 Special diets; radiation therapy, physiotherapy, respiratory therapy, physical, occupational,
speech therapy, and other forms of professional therapies while in the hospital.
A-2.11 Whole blood and blood products, including their administration. Fees incurred for
voluntary blood giving in autologous transfusion programs are covered.
A-2.12 In-hospital professional care covered services of health professionals, including any
medical specialist whose services are covered and deemed medically necessary and
ordered by the Member’s primary care physician and/or attending physician.
• Serious impairment to bodily functions, or
• Serious dysfunction of any bodily organ or part.
Further, emergency services means covered inpatient and outpatient services that are as
follows:
• Furnished by a provider that is qualified to furnish these services under this title.
• Needed to evaluate or stabilize an emergency medical condition.
Poststabilization care services means covered services, related to an emergency medical
condition that are provided after a Member is stabilized in order to maintain the stabilized
condition, or, to improve or resolve the enrollee’s condition.
Examples of emergency conditions might include but are not necessarily limited to:
unusual chest pain or problem breathing; puncture wound or nonstop bleeding; suspected
fracture or broken bone; severe bites, burns or blows to the head; and sudden loss of
strength or sensation in arms or legs.
Referrals or prior authorization are not required for emergency care. Members may go to
any emergency facility.
A-3.02 Procedure: If the Member considers his or her condition to be so serious or life threatening
that delay in seeking treatment might cause death, severe injury or serious impairment, the
Member should call 911 or seek help from the nearest medical facility as soon as possible.
If possible, it is also recommended that the Member attempt to contact his or her primary
care physician for medical advice. A Member who is unable to reach his or her primary
care physician may contact the Blue Cross Complete after hours call line for assistance at
1-800-228-8554, available 24 hours a day, seven days a week.
Blue Cross Complete strongly recommends that the Member contact his or her primary
care physician within 24 hours after seeking emergency services (or as soon as possible if
circumstances make 24 hours impossible) to arrange for additional follow-up medical care.
All follow-up care after an emergency must be provided or arranged by the Member’s
primary care physician. Follow-up care as a result of an emergency is considered routine
scheduled care that must be coordinated with the Member’s primary care physician.
A-3.03 Ambulance/Emergency Transportation: When necessitated by a need for emergency
services as defined above, appropriate ambulance transportation to the nearest hospital
where emergency care and treatment or other necessary services can be provided is a
covered benefit.
A-3.04 Transportation: When medically necessary nonemergent transportation is provided
to members to obtain covered services according to Michigan Department of Human
Services guidelines.
A-3.05 Transfers: Ambulance transportation between hospitals when authorized by Blue
Cross Complete shall be covered. When a Member receives medical care from a
nonparticipating hospital or facility, Blue Cross Complete may require a Member to be
transferred from the nonparticipating hospital or facility to a participating hospital when
the Member’s medical condition permits.
A-4. Diagnostic and therapeutic services and tests
A-3. Emergency services and related services
A-3.01 Definition: Medically necessary services provided to an enrollee for the sudden onset of a
medical condition that manifests itself by acute symptoms of sufficient severity, including
severe pain, such that the absence of immediate medical attention could reasonably be
expected to result in:
• Serious jeopardy to the health of the individual or in the case of a pregnant woman, the
health of the woman or her unborn child,
80
A-4.01 Diagnostic and therapeutic laboratory, pathology and radiology services and other
procedures for the diagnosis or treatment of disease, injury, or medical condition are
covered when ordered by the Member’s physician and/or arranged by Blue Cross
Complete.
Limited psychological testing shall be covered under this section for purposes of assessing
developmental status and/or as an outcome measure related to rehabilitation.
81
A-4.02 Certain genetic assessment services are covered but limited to techniques and procedures
approved by Blue Cross Complete.
A-4.03 Allergy tests, treatment, and injections are covered.
A-5. Home health services
A-5.01 Home health services will be provided to Members who are homebound as a result of
illness or injury. Services must be provided or arranged by the Member’s primary care
physician or designee, prior authorized by Blue Cross Complete and be provided by a
Blue Cross Complete contracted provider. Treatment must be intermittent.
Covered home health care services include: Home care nursing services by a registered
professional or licensed practical nurse; skilled care by a registered professional nurse or a
licensed practical nurse, physical therapist, occupational therapist, speech therapist. Home
health aides are covered in conjunction with other skilled home care needs. Personal care
or home help services are not covered. Drugs and biological solutions, surgical dressings
and related medical supplies used during home health care visits considered medically
necessary for the proper care and treatment of the Member’s condition will be covered.
A-6. Equipment to support home care
A-6.01 Equipment to support home care treatment as an alternative to hospital care may be
covered when medically necessary as defined in this Certificate. Equipment included
under this section must be hospital equipment (e.g., ventilators, dialysis equipment,
infusion pumps), monitors, and other items that are used in the home as an alternative
to hospital care and must require daily technical or professional supervision. Equipment
or items under this section must be obtained through a Blue Cross Complete approved
provider and ordered by the Member’s primary care physician or his or her designee and
A-7. Physical, occupational, and speech services
A-7.01 Restorative or rehabilitative physical, occupational, and speech therapy in an outpatient
facility is covered up to 36 visits within a 90 consecutive day period when ordered by
a Blue Cross Complete physician and authorized by Blue Cross Complete. Outpatient
physical and occupational services are covered up to 24 visits within a 90 consecutive
calendar period when provided in the home and ordered by a Blue Cross Complete
physician and authorized by Blue Cross Complete.
A-8. Cardiac rehabilitation services
A-8.01 Short-term cardiac rehabilitation therapy, when ordered by the primary care physician
or his or her designee, authorized by the Blue Cross Complete Medical Director and
provided by a participating provider, is a benefit under this Certificate.
A-9. Patient counseling and education
A-9.01 A limited number of visits for nutritional counseling provided by a registered dietitian are
covered when ordered by the Blue Cross Complete primary care physician. Members
diagnosed with chronic renal insufficiency, hyperlipidemia, hypertension, heart failure, or
obesity (with BMI of 35 or more for adults or with BMI-for-age of more than 85th percentile
for children ages 2-18) are covered for up to four visits per calendar year. Members
diagnosed with diabetes or pre-diabetes are covered for up to six visits per calendar
year. Members with gestational diabetes are covered for up to four visits per pregnancy.
Members with any combination of the above conditions are covered for up to four visits
per calendar years (six visits if one of the conditions is diabetes or pre-diabetes).
82
A-10. Skilled nursing facility
A-10.01 Short-term restorative health services up to 45 days within a 12-month rolling period from
initial admission of skilled care provided in a nursing home setting are covered benefits
if medically necessary and arranged and authorized by Blue Cross Complete. Long-term
custodial care is not covered. Individuals receiving long term custodial care, as determined
by MDHHS, will be disenrolled.
Skilled nursing home visits by physicians as part of the continued supervision of care are
covered. The Member must require skilled care on a daily basis and, as a practical matter,
considering economy and efficiency, the daily skilled care services can be provided only in a
skilled nursing facility. Custodial care is not a covered benefit under this section.
Ambulance transportation between skilled nursing facility and hospital when authorized by
Blue Cross Complete is covered.
A-11.Hospice
A-11.01 Hospice care services shall be a covered benefit when requested by the Member and
arranged and authorized by Blue Cross Complete. Included in this coverage is the room
and board component of the hospice benefit when provided in a nursing home or
hospital. Members who have elected the hospice benefit will not be disenrolled after 45
days in a nursing home as otherwise permitted by MDHHS.
A-11.02 Members under 21 years of age may receive hospice care concurrently with curative
treatment of the Member’s terminal illness. This allows the Member or Member’s
representative to elect the hospice benefit without forgoing any curative service to which
the Member is entitled under Blue Cross Complete for treatment of the terminal condition.
The need for hospice care must be certified by a physician and the hospice medical
director. Blue Cross Complete will reimburse for the curative care separately from the
hospice services. Blue Cross Complete will not reimburse for these types of treatments
when they are used palliatively. As such they are the responsibility of the hospice and must
be included in the per diem cost.
A-12. Hearing examination and hearing aids
A-12.01 Hearing examinations to determine whether a hearing problem exists are a covered
benefit for members. Services provided under this section are covered when medically
necessary and in accordance with Medicaid requirements. Services must be ordered by the
Member’s primary care physician and provided by a participating audiologist.
A-12.02 Hearing aids are covered for members under age 21. When a hearing aid is recommended
following a hearing examination conducted while a Member of Blue Cross Complete, the
following is covered for each Member once each fifth benefit year:
• Hearing aid examination to evaluate the Member for the specific type or brand of
hearing aid needed;
• For members under age 21, one single hearing aid unit (or one per ear if medically
necessary) including earphone (receiver or oscillator), ear mold, necessary cords, tubing,
and connections. The hearing aid unit must be a conventional amplification device. It
must also be an in-the-ear, behind-the-ear or on-the-body type, and identified as basic
to the Member’s amplification requirements;
• Fitting of the hearing aid including one follow-up visit to evaluate the performance of
the hearing aid and determine its conformance to prescription; and
• For all members, batteries, maintenance, and repair for hearing aids are covered.
A-12.03 Payment: The amount that would be paid by Blue Cross Complete for a conventional
hearing aid unit may be applied toward an upgraded aid, if desired by the Member.
83
A-13. Durable medical equipment, prosthetics and orthotics
A-13.01 Services provided under this section are covered when medically necessary and in
accordance with Medicaid requirements. Equipment or devices under this section must:
• Meet established Blue Cross Complete medical necessity screening criteria, and be
appropriate for use in the home,
• Be ordered by a Blue Cross Complete-contracted physician,
• Be authorized by Blue Cross Complete, and
• Be obtained through a Blue Cross Complete-contracted DME provider.
A-13.02 Prosthetic devices which aid body functioning or replace a limb or body part, including
breast prostheses after mastectomy, and their fitting are covered benefits. Replacement
prostheses needed because of growth or normal wear are also a covered benefit. Wigs,
prosthetic hair, or hair transplants are not covered benefits. Orthotic devices used to
correct a defect of body form or function are covered benefits. Orthotics, used for
stabilization due to medical reasons having the potential to functionally benefit members,
are covered benefits. Over-the-counter or custom-fitted braces are not covered benefits.
Prosthetic and orthotic (P&O) equipment or devices under these sections must:
• Meet established Blue Cross Complete medical necessity screening criteria,
• Be ordered by a Blue Cross Complete contracted physician,
• Be authorized by Blue Cross Complete, and
• Be obtained through a Blue Cross Complete contracted P&O provider.
A-13.03 Blue Cross Complete reserves the right to require use of the least costly medically effective
DME and prosthetic or orthotic devices.
A-14. Disposable medical items and other medical supplies
accordance with Medicaid requirements. Covered disposable medical items include
urological and ostomy supplies, peak flow meters, alcohol wipes, Betadine, and diabetic
supplies. Medical supplies in conjunction with home health care are also covered. Such
items are covered when ordered by a contracted physician, authorized by Blue Cross
Complete and obtained through a Blue Cross Complete contracted provider.
A-14.02 The diabetic management supplies listed below are covered when medically necessary
and in accordance with Medicaid requirements.
• Insulin needles and syringes.
• Lancets, test strips, and control solutions.
• Urine strips when medically indicated.
• Blood glucose monitors and batteries.
• External insulin pumps and insulin pump supplies for diabetic patients who on the basis
of blood tests are determined not producing insulin themselves.
A-15. Special provisions applicable to organ and tissue transplants
accordance with Medicaid requirements. Organ and tissue transplants which are not
considered to be experimental as defined in this Certificate and performed at a Blue Cross
Complete contracted facility will be considered on a case-by-case basis when:
These types of transplants include: kidney transplants, small bowel transplants, heart
transplants, heart-lung transplants, lung transplants, pancreas transplants, cornea
transplants, liver transplants, and bone marrow transplants. Organ and tissue transplant
procedures, which are considered experimental by Blue Cross Complete, are excluded.
Blue Cross Complete will pay for the hospital, surgical, laboratory, and X-ray services
incurred by a nonmember donor for an authorized transplant to a member unless the
donor has coverage for such expenses. Blue Cross Complete will not cover donor
expenses for a nonmember recipient.
A-16. Health services by nonplan providers
A-16.01 Health services rendered by non-plan providers must be requested in writing in advance
by the Member’s primary care physician and authorized in writing in advance by the Blue
Cross Complete Medical Director, except as otherwise stated in this Certificate.
A-17. Mental health services
A-17.01 Treatment for short-term mental health conditions is covered under this Certificate when
determined by Blue Cross Complete’s Behavioral Health department to be medically
necessary and within the scope of this Certificate. Coverage includes up to 20 days of
mental health outpatient visits when consistent with Medicaid rules.
Services must be authorized by the Blue Cross Complete Behavioral Health department,
and provided by a contracted individual or agency. The member may call Blue Cross
Complete Customer Service for assistance in finding a provider or contact a contracted
mental health provider directly.
A-17.02 Outpatient mental health service for crisis intervention and short-term therapy is covered
as determined by the Blue Cross Complete Behavioral Health department and not to
exceed a maximum of 20 outpatient visits per benefit year. The benefit is not intended to
support long-term psychotherapy.
A-18. Oral surgical services
A-18.01 The Member is covered for the following oral surgical services:
• Emergency surgery of the jaw or maxillofacial area due to trauma, accident or injury;
• Diagnosis and treatment of cysts, and benign and malignant tumors of the maxilla,
mandible and adjacent structures;
• Hospital and medical expenses for extractions, which must be performed in a hospital as
a result of an underlying critical medical condition; and
• Medically necessary medical or surgical, but not dental, management of internal
derangements of the jaw as determined by the contracted physician and authorized by
Blue Cross Complete.
A-19. Oral health screening and fluoride varnish
A-19.01 As part of the well-child visit (EPSDT), the member is covered for an oral health screen at
age 12 months and will be referred to a dentist if dental care is needed.
Fluoride varnish treatments for children up to age three (0-35 months) are covered.
Fluoride may be applied to teeth up to four times a year.
• Blue Cross Complete medical necessity screening criteria are met,
• Recommended by a transplant committee at a Blue Cross Complete contracted
provider, and
• Approved by Blue Cross Complete’s Medical Director.
84
85
Part 2: Schedule of limitations and exclusions
A-20. Chiropractic services
A-20.01 When considered medically necessary and provided by a contracted provider, chiropractic
coverage is limited to:
• Manual spinal manipulation and
• Radiological (X-ray) services provided by a chiropractor, limited to no more than one set
of X-rays of the spine per year.
The maximum number of visits covered by Blue Cross Complete is 18 visits per year.
Additional visits require prior authorization.
A-21. Vision
A-21.01 Routine eye examinations by a Blue Cross Complete-affiliated vision care provider
to determine the need for vision correction are covered. One exam is covered every
two years.
A-21.02 One pair of clear corrective lenses of any focal type, and eyeglass frames are covered
at Blue Cross Complete affiliated vision providers every two years. Sunglasses are
not covered.
A-21.03 Replacements for eyeglasses that are lost, broken, or stolen are covered twice per year for
members under age 21, and once per year for members age 21 and over.
A-21.04 Contact lenses are covered if the member has a vision problem that cannot be adequately
corrected by eyeglasses.
A-22. Podiatry services
A-22.01 Podiatry services that are medically necessary.
A-23. Prescriptions drugs and medicine
A-23.01 Medications that are covered when ordered by a Blue Cross Complete contracted
physician are listed in the Blue Cross Complete Preferred Drug List.
A-23.02 Medications covered when obtained at a Blue Cross Complete contracted pharmacy.
A-23.03 Injectable insulin, insulin syringes and needles, contraceptive medications, diaphragms
and IUDs are covered Blue Cross Complete benefits.
A-23.04 Certain over-the-counter medicines are covered with a prescription.
A-23.05 All prescriptions are limited to a 34-day supply.
A-23.06 Generic substitution is required when an equivalent generic drug is available and
appropriate. Prior authorization is required for coverage of brand products where a generic
equivalent is available.
A-23.07 Prior authorization, quantity limits or other restrictions may be required for some
medications for coverage.
Excluded are services not covered by this Certificate of Coverage as described
below, even when recommended by a primary care physician. Services obtained by a
Member that are not approved by the primary care physician and/or authorized by Blue
Cross Complete, and/or not provided by participating providers or facilities, are not
covered benefits. (Certain exceptions apply; e.g., Emergency Services, Section A-3.)
All nonmedically necessary related expenses in connection with excluded services and
benefits are not covered.
Blue Cross Complete excludes services, technology, or drugs which are experimental
or which are being used for experimental purposes, including, but not limited to, those
approved by the FDA for testing or study on humans. Any service, technology, or drug
may not be covered by Blue Cross Complete if it is not recognized as safe and effective
for its intended use, based on generally accepted medical standards. Antineoplastic drug
therapy is a covered benefit in accordance with Michigan law. For more information, call
Customer Service.
A-24. Limited and excluded services
A-24.01 DENTAL SERVICE
Except as indicated in A-18, and services rendered as part of EPSDT, dental service is
excluded. Some services may be covered by the state of Michigan.
A-24.02 SERVICES NOT MEDICALLY NECESSARY
Determination of medical necessity will be a judgment of the Blue Cross Complete
Medical Director consistent with the Medicaid program requirements. Except as expressly
provided herein, services which are not medically necessary are not covered under this
Certificate.
A-24.03 SERVICES REQUIRED BY OTHERS
Except as provided in Section A-1, office visits, examinations, treatment, drug testing,
employment-related examinations, and other services that are required by third parties to
document health status or for other required purposes are not benefits.
A-24.04 ELECTIVE COSMETIC SURGERY/PROCEDURES
Cosmetic surgery, procedures, and medications designed to reshape the body or alter
the appearance, are excluded. This includes, but is not limited to, elective rhinoplasty,
spider/varicose vein repair, elective breast reconstruction, and radial keratotomy. Cosmetic
alteration done simultaneous to surgery for a medical condition is also excluded unless
determined medically necessary by Blue Cross Complete. Hair transplants are not a
covered benefit.
A-24.05 CUSTODIAL OR DOMICILIARY CARE
Custodial or domicillary care is excluded.
A-24.06 PRIVATE DUTY NURSING SERVICES
Private duty nursing services are excluded.
A-24.07 NONMEDICAL SERVICES
Nonmedical services such as on-site vocational rehabilitation and training or work
evaluations, home or worksite environmental evaluations, or related employee counseling
are excluded.
A-24.08 EXPERIMENTAL/INVESTIGATIONAL DRUGS, PROCEDURES OR EQUIPMENT
All experimental/investigational drugs, procedures or treatment are excluded.
86
87
A-24.09 OTHER NONSTANDARD MEDICAL PROCEDURES
Procedures and treatments which are not considered standard practice by Blue Cross
Complete or which are primarily educational in nature are not covered, e.g., biofeedback,
acupuncture, hypnosis, PMS, dyslexia, caregiver training programs; extended behavior
modification programs for chronic mental illness; exercise programs, etc.
A-24.10 PERSONAL AND CONVENIENCE ITEMS
Personal and convenience items are excluded.
A-24.11 OTHER COVERAGES
Treatment is excluded for any injury or sickness on which and to the extent any benefit
settlements, benefit payments, awards, or damages are received or payable under
Worker’s Compensation, any insurance plan, or state or federal legislation, Community
Mental Health Agencies or other third party payer.
A-24.12 MENTAL HEALTH
Coverage of treatment for chronic mental health is excluded, in the absence of an acute
episode. Long-term psychotherapy is not a benefit. Partial hospitalization in a day-or-night
care program is not covered. Inpatient psychiatric care is not covered. Court ordered
examinations to determine competence and expenses of expert witness testimony as to
the mental condition of a Member are excluded.
A-24.13 SUBSTANCE ABUSE SERVICES
Substance abuse services (including substance abuse treatment drugs) are not covered
benefits for Members through Blue Cross Complete. Substance abuse services are
available to Members through their local substance abuse coordinating agencies. If you
need assistance in contacting your local substance abuse coordinating agency, please
contact Customer Service.
A-24.14 REPRODUCTIVE SERVICES
Reversal of voluntary sterilization, including tubal reanastamosis, is not a benefit. Services
for treatment of infertility are not covered.
Assisted Reproductive Technologies (ART) including, but not limited to: artificial
insemination, intrauterine insemination, in vitro fertilization, gamete intrafallopian transfer
(GIFT), zygote intrafallopian transfer (ZIFT), donor egg/donor sperm programs, cryology,
micromanipulation, and any related diagnostic and therapeutic services unique to these
technologies are excluded from coverage.
A-24.15 TRANSSEXUAL SURGERY
A-24.18FORMS
Physician and professional staff time required for the completion of forms unrelated to
medical care provided is excluded.
A-24.19 CHARGES FOR MISSED OR NO-SHOW APPOINTMENTS
Fees imposed by a health care facility for a missed or no-show appointment are not
covered by Blue Cross Complete and are the financial responsibility of the patient.
A-24.20 ROUTINE FOOT CARE
Podiatry services that are not medically necessary.
A-24.21 VISION SERVICES
Not covered except as indicated in A-21.
A-24.22 SPECIAL FOOD AND NUTRITIONAL SUPPLEMENTS
Food and food supplements are not covered, except for enteral feedings when they are
the sole means of nutrition or when used as part of the Maternal Infant Health Program
(MIHP).
A-24.23 DURABLE MEDICAL EQUIPMENT, PROSTHETICS, AND ORTHOTICS
Excluded from coverage are: replacement and/or repair of any covered item due to
misuse, loss or abuse; experimental items; comfort and convenience items such as, but
not limited to, over-bed tables, electric heat pads, exercise equipment, adjusta-beds,
air conditioners or purifiers, whirlpools, and elevators. Also excluded under this section
are any durable medical equipment, prosthetics and orthotics excluded from coverage
by MDHHS.
A-24.24 SECOND OPINIONS
Members may obtain a second opinion about treatment or procedures recommended
by a Blue Cross Complete participating physician. Second opinions about treatment
or procedures recommended will be considered on a case-by-case basis, requires
authorization by the Blue Cross Complete Medical Director, and must be provided by
a physician approved by Blue Cross Complete.
A-24.25 PHYSICAL EXAMINATIONS REQUIRED FOR SCHOOL, CAMP, OR MARRIAGE LICENSE
APPLICATIONS
Physical examinations for school, for camp registration, or in connection with a marriage
license application are excluded.
A-24.26 ELECTIVE ABORTIONS
Sex-transformation surgery and all expenses in connection with such surgery are not
covered benefits.
A-24.16 AUTOMOBILE ACCIDENTS
Benefits are not provided for services for treatment of any automobile related injury for
which the Member’s health care expenses are covered under an automobile insurance
policy (see Section 11).
A-24.17 WEIGHT REDUCTION
Commercial or medical programs solely for weight reduction and control are not covered.
Limited coverage is available when treatment of obesity is for the purpose of controlling
life-endangering complications such as hypertension and diabetes. If conservative weight
control measures have failed, other weight reduction efforts may be approved. The
Member’s physician is required to obtain prior authorization from Blue Cross Complete.
88
Elective abortions are not covered unless the pregnancy is the result of rape or incest,
and requires referral by the primary care physician. Treatment for medical complications
occurring as a result of an elective abortion is covered.
A-24.27 SELECT PRESCRIPTION DRUGS
Blue Cross Complete does not provide coverage for certain types of medications and
medical supplies. The following drugs are not provided through Blue Cross Complete:
• Drugs that require prior authorization, but are not prior authorized by Blue Cross
Complete
• Drugs used to promote smoking cessation that are not on the Michigan Pharmaceutical
Product List (MPPL)
• Over-the-counter drugs that are not on the MPPL
• Vitamins and mineral combinations unless prescribed for end stage renal disease,
pediatric fluoride supplementation or prenatal care
89
Mackinac
Dickinson
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Drugs used for the symptomatic relief of cough and colds
Cosmetic drugs or drugs used for cosmetic purposes
Drugs used for infertility
Drugs used for sexual dysfunction
Drugs used to treat gender identity conditions, such as hormone replacement
Drugs used for the treatment of substance abuse
Drugs used for anorexia or weight loss (unless authorized)
Food supplements and standard infant formulas
Drugs that are not approved by the FDA
Drugs used for experimental or investigational purposes
Drugs prescribed specifically for medical studies
Prescriptions filled after you are no longer a Blue Cross Complete member
Prescriptions that provide more than a 34-day supply beyond your termination date
Drugs included as a health care benefit, such as vaccines and other injectable drugs that
are normally administered in a physician’s office
Drugs covered by another plan, including Medicare Part D
New drugs not yet added to the formulary
Drugs recalled by the labelers, and drugs discontinued past one year ago
Drugs acquired without cost to the providers or included in the cost of other services or
supplies
Drugs used for HIV or AIDS (coverage is provided by the state of Michigan)
Drugs used for certain types of mental illness (coverage is provided by the state
of Michigan)
Compounded products that contain bulk powders (unless authorized)
Prescriptions that have been adulterated or are fraudulent
Some drugs provided by the state of Michigan are not covered by Blue Cross Complete.
Members may refer to michigan.fhsc.com for more information about these drugs.
• Drugs used for HIV or AIDS
• Drugs used for seizure disorders
• Drugs used for sleep disorders
• Drugs used for mental health
A-24.28 LAW ENFORCEMENT CUSTODY
Care rendered while the Member is in the custody of law enforcement officials, except for
off-site inpatient hospitalization consistent with MDHHS policy, are excluded.
A-24.29 ILLEGAL SERVICES
Services that are illegal are excluded.
A-24.30 COURT RELATED SERVICES
Delta
Emmet
Menominee
Cheboygan Presque
Isle
Service Area
Charlevoix
Montmorency
Alpena
Grand Kalkaska Crawford Oscoda
Benzie Traverse
Alcona
Manistee Wexford MissaukeeRoscommon Ogemaw
Iosco
Antrim
Otsego
Leelanau
Mason
Osceola
Lake
Clare
Gladwin
Arenac
Huron
Oceana
Newaygo
Mecosta Isabella Midland Bay
Montcalm Gratiot
Muskegon
Ottawa
Allegan
Kent
Genesee
ShiaClinton wassee
Ionia
Barry
Saginaw
Tuscola
Eaton
Van Kalamazoo Calhoun
Buren
Washtenaw Wayne
Pretrial or court testimony and the preparation of court related reports are excluded.
Berrien Cass St. Joseph Branch Hillsdale
90
Lapeer
Ingham Livingston Oakland
Jackson
Lenawee
Monroe
Sanilac
St. Clair
Macomb
Return Mail Processing Center
PO Box 018
Essington, PA 19029-0018
Blue Cross Complete of Michigan LLC is an independent licensee of the Blue Cross and Blue Shield Association.
WP 7331 JAN 16
MH-01/Rev12/2/15
R047859

Blue Cross Complete Member Handbook

Transcription

Similar documents

GROUP VISION CLAIM FORM EMPLOYEE

SLEEP ON IT - The PassTime Paper

SLEEP ON IT - Rights Reserved © 2016

Silhouette Soft2

Listing Flyer - Former Crusty`s Pizza

August 2015

Heart failure: how can I help myself?

17 Jan 2015

VI CTP Brochure

Certificate of Registration Evans Chemetics LP