Untitled - Health Net of West Michigan

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Welcome to WellNet!
Inside this handbook, you will find the tools you need to understand your WellNet coverage.
At Health Net of West Michigan, our goal is for you to feel empowered, supported and respected while
being a part of this program.
If you ever have any questions, please contact our office (616-726-8204); we
would love to help.
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Table of Contents
Summary Notice of Privacy
Practices
Grievances & Appeals
4
5
Member Rights
Member Responsibilities
Member Requirements
7
Medical Co-payments and
Covered Services
8
WellNet ID Card
9
Referrals and Prior
Authorizations
9
Clinics Accepting WellNet
10
Urgent Care Centers Near You
11
Emergency Room
11
Pharmaceutical Products
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Participating Pharmacies
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If You Receive a Bill
14
Annual Review
14
Case Management
15
Health Education Classes
15
Health Management
15
Transportation
16
Communication with our Office
16
Important Information
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HEALTH NET OF WEST MICHIGAN
SUMMARY NOTICE OF PRIVACY PRACTICES
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.
Health Net of West Michigan (HNWM) is required by law to provide a Notice of Privacy Practices that tells how
health information that we have about you may be used or disclosed by us. It also tells you about your rights. The
full Notice, which you have also received, gives more details about these things. You may ask for another copy of
the full Notice at any time. We may change our Notice of Privacy Practices and will make the revised Notice
available via our website or will provide you with a paper copy upon request.
Uses and Disclosures:
HNWM may use and disclose your health info for a number of reasons without asking or telling you. These include:
• paying providers for your health care services
• running our health plan
• preventing a serious threat to the health or safety of yourself or another person
We may sometimes be required by law to disclose certain health info about you.
Other uses and sharing of your health info not stated in the full Notice can only be done with your written consent.
Your Rights:
You have rights when it comes to your health info. These include:
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asking for limits on how we use and disclose your health info to others
asking for limits how we share info with you
asking us to correct mistakes in your health info
filing a complaint if you feel your rights have been violated
Questions or Complaints:
If you have questions about the Notice or if you feel your rights may have been violated and want to file a
complaint, contact:
Privacy Officer
Health Net of West Michigan
620 Century Ave. Suite 210
Grand Rapids, MI 49503
(616)726-8204
You may also file a complaint with the Office of Civil Rights, Department of Health and Human Services, 233 N.
Michigan Ave. Suite 240, Chicago, IL 60601 (1-800-368-1019). We respect your right to protect the privacy of your
health information and we will not take action against you if you file a complaint in good faith with us or with the
U.S. Department of Health and Human Services.
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Grievances and Appeals
Definitions
A Grievance is a complaint. For example, you may want to file a Grievance if you are unhappy with the
way a Health Net staff person or one of our participating doctors treated you.
An Appeal is a request for review of a denial of coverage. For example, you may file an Appeal if Health
Net refuses to cover a service or medication.
Filing a Grievance or Appeal
You can request the paperwork to file a Grievance or Appeal with Health Net of West Michigan in-person
or by calling 616-726-8204 and asking to speak with the Compliance Officer. You may also request the
paperwork by sending a fax to the Compliance Officer at 616-726-8205 or by writing to:
Compliance Officer
Health Net of West Michigan
620 Century Ave. Suite 210
Grand Rapids, MI 49503
A Grievance form or Appeal form will need to be filled out and turned in to Health Net in order for the
process to begin. The Compliance Officer or other staff person can help you with filling out the
paperwork.
You (or your authorized representative) may file a Grievance or Appeal with Health Net of West Michigan.
You may allow any adult (including a doctor, friend or family member) to act on your behalf as an authorized
representative as long as you provide Health Net with a written authorization. We will provide you with the
authorization form and we can help you fill it out.
Grievances
If you have an issue or complaint that Health Net staff are unable to resolve, you may file a Grievance. A
Grievance must be submitted in writing to Health Net within 90 days of when the problem or issue
occurred. The Grievance will be reviewed by the Health Net Management Council and a decision will be
made within 35 days.
One or more members of the Council may attempt to contact you to get more info or to try to resolve the
issue. If we are not able to reach you, a decision will be made based on the info the Council has. You will be
sent written notice of the determination or resolution. A member of the Council may also contact you by
phone to discuss the outcome. Any decision or course of action, as determined by the Management Council, is
final.
Standard Appeals
An Appeal must be submitted to Health Net within 90 days of the notice of a change in or denial of
coverage for services.
The decision on a non-expedited Appeal will be made by Health Net’s Medical Director within 35 days after
Health Net receives the Appeal in writing. This may be extended by up to 10 business days if more info is
needed. You will be sent written notice of the decision.
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Expedited Appeals
An Appeal will be expedited if a doctor supports (verbally or in writing) that the standard timeframe for an
Appeal decision would pose a serious threat to your life or health. A request for an Expedited Appeal can
be made verbally or in writing by you or your doctor. It must be made within 10 days of the notice of
the change in or denial of coverage for a service.
A decision on an Expedited Appeal will be made by Health Net’s Medical Director within 72 hours of when
it is received. Health Net will make a reasonable effort to notify you about whether your request for an
Expedited Appeal was accepted. The standard 35-day timeframe will go into effect if you request more time
or if Health Net denies the Expedited request.
Appealing an Appeals Decision
If your initial Appeal is denied, you may file another Appeal. A decision will be made by Health Net’s
Clinical Committee within 35 days after Health Net receives the second Appeal in writing. The decision of
Health Net of West Michigan’s Clinical Committee is final.
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Member Rights:
You have the right to:
• be treated with respect and not be discriminated against by Health Net staff or participating providers on the
basis of race, color, creed, national origin, language, height, weight, disability, religion, political affiliation or
beliefs, sex , marital status, sexual orientation, gender identity or expression, age, criminal history, or
socioeconomic status.
• receive information about your health coverage, such as covered and non-covered services, program
requirements, and any medical costs that you may have to pay.
• have access to a current list of in-network doctors and pharmacies, along with other places you can receive
care.
• select and change your primary care doctor
• be informed about your healthcare, receive information about proposed treatments, and participate in
decisions about your care with your doctor and other healthcare professionals.
• have the privacy of your personal information protected, as required by law.
• voice complaints or file a Grievance about Health Net of West Michigan, the WellNet program, or a
participating provider without fear of retaliation and to receive a timely response to your concerns.
• file an appeal regarding a non-covered or denied service and receive a timely determination
Member Responsibilities:
• Act in a considerate and respectful manner to other Health Net members, Health Net staff, and healthcare
providers.
• Notify Health Net of:
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o Change in income or family size
o Change in address, phone number, or name
o Getting other health coverage (from employment, Medicare, Medicaid, Healthy Michigan Plan, etc.)
o Pregnancy
Ask questions if you do not understand something.
Keep appointments and be on time. Contact the place where you have an appointment right away if you are
going to be late. If you need to cancel an appointment, do so at least 24 hours in advance.
Provide honest, complete info to your healthcare providers and Health Net staff.
Know what medicine you take, why, and how to take it.
Learn about your health problems, how to manage them, and how to avoid health problems.
Take part in healthy behaviors.
Use emergency room services only for injury and illness that, in the judgment of a reasonable person, require
immediate treatment to avoid serious danger to life or health.
Tell your doctor any concerns or problems you have about your health or treatments.
Obtain medical care and prescriptions from your designated provider and pharmacy.
Let Health Net know if you need to receive information in a different language or format.
Member Requirements:
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Have an annual physical exam.
Take responsibility for, and actively participate in, improving and maintaining your health.
Attend health related classes as required by the WellNet program.
Do not misuse your health coverage or the services provided.
I understand that violation of member responsibilities and/or requirements could result in the termination of my
WellNet health coverage as provided by Health Net of West Michigan.
______________________________________
Sign
_________________________
Date
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Medical Co-payments and Covered Services:
Below is a chart that shows all of the services that WellNet covers as well as the costs. If you have any
questions about whether or not a service is covered, contact our office at 616-726-8204.
If a service is not listed, please contact our office BEFORE your appointment to make sure the
service will be covered.
Copay
Comments/Requirements
Visits to Medical Home
Specialist Office Visits
Physical Therapy
Wound Care
Service
$5
$5
$5/visit
$5/visit
Glucose Meters
No cost
Annual physical exam required
Referral from PCP for prior approval (4 visits/year)
Referral from PCP for prior approval (up to 6 visits/year)
Covered in certain settings – Prior Authorization required
Free for members diagnosed with Diabetes (limit on # of
strips covered)
Must contact Medical Home prior to going/ does not cover
facility fee*
Must contact Medical Home prior to going
Must be medically necessary
Prior authorization required/does not cover facility fee*
No prior authorization required
No prior authorization required
Prior authorization required unless life-threatening
condition
Prior authorization required unless life-threatening
condition
Prior authorization required
Prior authorization required
Prior authorization required
Prior authorization required
Refer to Women’s Health Network
Prior Authorization required
Prior authorization required/does not cover facility fee*
Urgent Care
Emergency Room
Ambulance
Outpatient Procedures/Surgery
Outpatient Labs
X-Rays
$5
$40
$40
$60
No cost
No cost
CT
$25
MRI
$25
Nuclear Stress Testing
No cost
Angiography
No cost
Pulmonary Function Test
No cost
EGD
No cost
Mammography (Over age 40)
Not covered
Mammography (Under age 40)
No cost
Colonoscopy (Diagnostic)
No cost
Colonoscopy (Screening - ages
No cost
Prior authorization required/does not cover facility fee*
50+)
* A facility fee is an extra charge not covered by WellNet. You will be responsible for this charge.
Additional services covered:
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Annual physical exams
Flu shots
Treatments for minor burns or skin irritations
Removal of warts or small moles
Blood pressure screening
Simple hearing tests (at Primary Care Physician’s (PCP) office only)
Simple laboratory tests
Routine care for minor medical problems such as colds, flu and back pain
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WellNet ID Card:
Each member will receive an ID Card.
Keep this card and use it when you go to the doctors or pharmacy.
This card is used for:
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Doctor Visits
Specialist Services
Outpatient lab tests
Outpatient imaging
Outpatient procedures
Prescriptions
Walk-in/ Urgent Care
Emergency room visits
You will need a new card if:
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Your doctor changes
Your pharmacy changes
To receive a new card, contact our office at 616-726-8204
If you go to the doctor or the pharmacy and they tell you that you do not
have coverage, please call our office as soon as possible.
Referrals and Prior Authorizations:
Some medical services require a referral. A doctor’s office uses a form to send patients to other doctors or
to have tests done. The request can be made to WellNet by the physician or the hospital. Health Net staff
will handle all the referrals that come from the doctor. Some medical services need “prior authorization”
from WellNet. A “prior authorization” is approval from WellNet for you to receive the service.
To see a list of the things that need prior-approval, refer to page 7.
If you have a service done that requires a prior authorization and there is NOT one on file, you will
receive a bill. If this happens, call our office IMMEDIATELY so we can help you.
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Clinics Accepting WellNet
Below is a chart that shows where you can go to the doctor. If you change your doctor, please call our
office so we can send you a new card.
CLINICS ACCEPTING WELLNET
METRO HEALTH
(charges facility fee)
ST. MARY'S
CHERRY HEALTH SERVICES
Clinic
Phone
Address
City
State
Zip
Languages
spoken
Belknap Commons Health Center
616-742-9945
751 Lafayette NE
Grand Rapids
MI
49503
Spn, Eng
Cherry Street Health Center
616-235-7272
550 Cherry St SE
Grand Rapids
MI
49503
Spn, Eng
Heart of the City
616-965-8200
100 Cherry Street
Grand Rapids
MI
49503
Spn, Eng
Durham Clinic(Requires Site Approval)
616-965-8283
100 Cherry St. SE
Grand Rapids
MI
49503
Eng
Montcalm Area Health Center
616-225-9650
1003 N. Lafayette
Greenville
MI
48838
Spn, Eng
669 Stocking NW
Grand Rapids
MI
49504
Spn, Eng
2929 Burlingame Ave SW Grand Rapids
MI
49509
Eng
Westside Health Center
616-235-1480
Wyoming Community Health Center
616-965-8333
Burton Health Center
616-247-3638
2135 Buchanan SW
Grand Rapids
MI
49507
Spn, Eng
Clinica Santa Maria
616-685-8400
730 Grandville SW
Grand Rapids
MI
49503
Spn, Eng
Heartside Health Center
616-685-3800
359 S. Division
Grand Rapids
MI
49503
Spn, Eng
Sparta Health Center
616-685-1300
475 S State St Sparta
MI
49345
Spn, Eng
Browning Claytor Health center
616-685-8300
1246 Madison SE
Grand Rapids
MI
49507
Spn, Eng
Metro Health Community Clinic
616 252-4100
781 36th SE
Wyoming
MI
49548
Spn, Eng
Spectrum Internal Medicine Residency
Practice (charges facility fee)
616-391-3777
25 Michigan NE #2100
Grand Rapids
MI
49503
Eng
Catherine's Care Center
616-336-8800
1211 Lafayette Ave NE
Grand Rapids
MI
49505
Eng
Health Interventions Services (HIS)
616-475-8446
15 Andre SE
Grand Rapids
MI
49507
Spn, Eng
OTHER
SPECTRUM
HEALTH
SPECTRUM HEALTH
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Urgent Care Centers near You
WellNet covers visits to Urgent Care for a co-pay of only $5.
If need to see a doctor and your doctor’s office is not open, you can go to Urgent Care.
Mercy Health Urgent Care at East Beltline
1741 East Beltline NE
Grand Rapids, MI 49525
616-685-3414
Spectrum Health Urgent Care Alpine
2332 Alpine Ave NW
Grand Rapids, MI 49544
616-391-6220
Emergency Room
Mercy Health Urgent Care Rockford
6050 Northland Drive
Rockford, MI 49341
616-685-7961
Spectrum Health Urgent Care Broadmoor
3350 Broadmoor Ave SE
Grand Rapids, MI 49512
616-391-8020
Spectrum Health West Pavilion Urgent Care
6105 Wilson Ave SW
Wyoming, MI 49418
616-486-5100
WellNet covers visits to the Emergency Room ONLY IF it is a TRUE medical emergency.
A medial emergency:
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puts your health or life in serious danger
could cause permanent or long term damage to your body
If you go to the emergency room and it is NOT a medical emergency, YOU will receive a bill.
If you are not sure if you should go to the Emergency Room, remember:
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call your doctor
you can go to any of the Urgent Care centers listed above
Pharmaceutical Products
WellNet covers most generic medications under $30.
WellNet will only cover a 30-day medication supply.
Because medication prices change often, we have changed how you will pay for your medications. The
chart below shows how much you will have to pay for each medication based on the cost.
Medication Cost
$0-$30
$30.01 - $50
$50.01 and above
Formulary Glucose Strips (max of 100 per month)
Co-Pay
$4
$10
Member must pay 100% of the network rate cost
$10
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If you go to the pharmacy and are told you do not have WellNet coverage, call our office
IMMEDIATELY to see why you cannot get your medications.
The following pharmacy benefits are not covered:
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The administration or injection of any prescription
Any refill of a prescription if it is more than the number of refills stated on the medicine bottle
Any prescription given to a member if they are in an inpatient facility
Participating Pharmacies
*This pharmacy delivers medications right to your door. Ask the pharmacy for more details
Ada Hillside Pharmacy
6745 E. Fulton St., Ada, MI 49301
(616) 682-9100
Allegan Community Pharmacy
115 Locust St., Allegan, MI 49010
(269) 673-4188
Chemist Shoppe*
1900 Wealthy St. SE, Grand Rapids, MI 49506
(616) 774-7799
D & W Fresh Market Pharmacy – Knapp’s
Crossing
2022 Apple Orchard Ave., Grand Rapids, MI
49525
(616) 361-3676
Family Fare Pharmacy – Kentwood
6127 Kalamazoo Ave. SE, Kentwood, MI 49508
(616) 698-8234
Family Fare Pharmacy – Lake Michigan Dr.
2755 Lake Michigan Dr. NW, Grand Rapids, MI
49504
(616) 791-4777
Family Fare Pharmacy – Leonard and Fuller
1225 Leonard St. NE, Grand Rapids, MI 49505
(616) 459-6203
Family Fare Pharmacy – Metro Health Village
2275 Health Dr. SW, Wyoming, MI 49519
(616) 249-9161
Family Fare Pharmacy – Breton Meadows
4325 Breton Rd. SE, Grand Rapids, MI 49512
(616) 281-5442
Family Fare Pharmacy – Northland Dr.
5241 Northland Dr., Grand Rapids, MI 49525
(616) 447-2788
Family Fare Pharmacy – Byron Center
2245 84th St. SW, Byron Center, MI 49315
(616) 878-6047
Family Fare Pharmacy – Rockford
201 Marcell Dr. NE, Rockford, MI 49341
(616) 863-9376
Family Fare Pharmacy – Fulton Heights
1415 E Fulton St., Grand Rapids, MI 49503
(616) 774-9422
Family Fare Pharmacy – Roger’s Plaza
1148 28th St. SW, Wyoming, MI 49509
(616) 724-1944
Family Fare Pharmacy – Grandville
3960 44th St. SW, Grandville, MI 49418
(616) 530-4590
Family Fare Pharmacy – Sparta
565 S. State St., Sparta, MI 49345
(616) 887-8861
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Family Fare Pharmacy – Wyoming
2900 Burlingame Ave. SW, Wyoming, MI 49509
(616) 538-1490
Grice’s Pharmacy*
6 N. Main St., Kent City, MI 49330
(616) 678-5380
Heart of the City Pharmacy
100 Cherry St. SE, Grand Rapids, MI 49503
(616) 965-8278
Kay Pharmacy*
2178 Plainfield Ave. NE, Grand Rapids MI 49505
(616) 361-7319
Meijer Pharmacy – Standale
315 Wilson Ave. NW, Standale, MI 49544
(616) 735-2110
Momber Pharmacy*
11 S. State St. NW, Sparta, MI 49345
(616) 887-7323
Parkwood Pharmacy*
1106 Burton St. SW, Wyoming, MI 49509
(616) 245-2463
Professional Pharmacy
9175 Cherry Valley Ave. SE #6, Caledonia, MI 49316
(616) 891-1116
Keystone Pharmacy*
4021 Cascade Rd. SE, Grand Rapids, MI 49546
(616) 974-9792
Leppink’s Pharmacy - Belding
115 Pearl St., Belding, MI 48809
(616) 794-4053
Leppink’s Pharmacy – Howard City
730 Shaw Ln, Howard City, MI 49329
(231) 937-4334
Meijer Pharmacy – 28th and Kalamazoo
1540 28th St. SE, Grand Rapids, MI 49508
(616) 452-9651
Meijer Pharmacy – Alpine
2425 Alpine NW, Grand Rapids, MI 49544
(616) 364-6281
Meijer Pharmacy - Greenville
606 S. Greenville W. Dr., Greenville, MI 48838
(616) 225-7710
Meijer Pharmacy - Lowell
11901 Fulton St., Lowell, MI 49331
(616) 897-4700
Saint Mary’s Cathedral Square Pharmacy
360 S. Division Ave. Ste. 1A, Grand Rapids, MI
49503
(616) 685-1147
Saint Mary’s Family Pharmacy
300 Lafayette Ave. SE, Grand Rapids, MI 49503
(616) 685-6105
Saint Mary’s Southwest Family Pharmacy
2373 64th St., Ste. 1100, Byron Center, MI 49315
(616) 685-3950
Village Pharmacy*
4252 Kalamazoo Ave. SE, Grand Rapids, MI
49508
(616) 281-1323
Walker Street Pharmacy*
1181 Walker Ave. NW, Grand Rapids, MI 49504
(616) 458-9640
Westside Pharmacy
669 Stocking Ave. NW, Grand Rapids, MI 49504
(616) 235-1480
Woodpointe Pharmacy*
2500 East Beltline Ave. SE, Grand Rapids, MI
49546
(616) 949-4499
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If You Receive a Bill:
If you receive a bill for a service that you believe should be paid for by WellNet, call the number on the
bill and explain that you have WellNet.
The name of your coverage was once called Plan B. Please let the billing location know that the name has
changed to WellNet. While on the call, make sure the company has the proper billing information found
on the WellNet card. If you are still having problems, call our office and we will try our best to assist you.
Do NOT ignore the bill.
Do NOT assume WellNet has paid the bill.
Do NOT throw it in the trash.
Contact our office. We are here to help.
Annual Reviews:
Each year during your birthday month, you will need to come to our office to reapply for the program. To
make sure you never miss the date you need to reapply, your review date is on the back of your WellNet
card.
On the 1st of your birthday month, WellNet will send you a letter telling you to call our office to schedule
a 15-minute appointment to reapply for the program.
When you come to this appointment you must bring:
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Proof of your household income from the last 30 days
Piece of mail sent to you that shows your name and address that was postmarked within the last
30 days
o For example, if your meeting with us is on May 25, the piece of mail you bring must have
a date on it between April 25 and May 25.
If you do not call our office by the 15th of the month to schedule an appointment with us, your
plan will be terminated
If you lose your WellNet coverage, it can be very hard to get it back. This is why it is very important that
we always have your updated contact information. If it is the first of the month and you did not get
your letter to reapply to WellNet, call us IMMEDIATELY
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Case Management:
As a WellNet member, you have access to FREE Case Management.
Call our office and ask to speak with a Case Manager if you need connection to:
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Transportation Resources
Behavioral Health Services
Health coaching and resources
Other resources that are not health related
Health Net is here to assist you in any way we can.
Health Education Classes Offered by Health Net of West Michigan
Health Net of West Michigan offers free health education classes taught by our health education team and
partner organizations. To make it easier to take part in classes, some classes are offered on-site at Health
Net and others are at community locations throughout West Michigan. Some health education classes are
offered in Spanish. Health Net is always looking to expand the education offerings. Check back often to
see if we have added a class.
Patient Empowerment
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Offers tools on how to talk to your doctors about your health and how to keep track of changes in
your health. The class tells what a medical home is and how it helps make care for you and your
doctors easier.
Stress Management
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Provides info on what stress is, knowing how stress affects daily life and healthy ways to handle
stress in your life.
Eat Right, Be Active!
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Follows the MyPlate program, which talks about what our body needs from food to be healthy,
how to read food labels and shopping for healthy foods on a budget.
Health Management
You must have a physical 90 days after attending orientation. If you have had a physical within the last 90
days, you do not need to go again.
If you need help scheduling this appointment, contact our office at 616-726-8204.
If you need transportation to this appointment, contact our office at 616-632-1015.
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Transportation:
If you need transportation to your medical appointments, Health Net of West Michigan can help!
Setting up transportation is easy.
If you need transportation, call the Transportation Line at Health Net of West Michigan
at 616-632-1015.
Our staff will walk you through the process. It’s simple, just call the transportation line at least 2 hours
before your appointment and we can arrange qualifying transportation.
Communication with our Office:
It is very important that you contact our office whenever you have life changes that could affect your
WellNet coverage. Most of our communication with you happens through the mail or by telephone.
You need to contact WellNet if you:
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have changes in your income
change your contact information (i.e address, phone number, etc.)
receive a bill
are told by your doctor’s office or pharmacy that your coverage is terminated
receive a letter from Health Net that you do not understand
get married
become pregnant
are leaving Kent county for 60 days or more
are no longer a resident of Kent county
are approved for Disability coverage
have a medical lawsuit
are eligible for other health coverage, including Medicare, Medicaid, Healthy Michigan Plan
(HMP) or private insurance
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Important Information:
Health Net of West Michigan
Transportation Line
General WellNet Questions
WellNet Clinical/Medical Questions
616-726-8204
616-632-1015
616-421-4829
616-421-4816
Your Medical Home
Your Pharmacy Home
You will receive your annual review letter
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