FAQs For our Members

 

Community FAQ's - click to expand

Why do I need to select a Primary Care Physician (PCP)?

Your PCP is your main doctor and works closely with you to coordinate your health care needs. He or she will send you to a specialist when it is medically necessary. Each family member covered by MHP Community must choose a PCP in our network. You can find the provider directory at McLarenHealthPlan.org. The provider directory will give you a list of PCPs to choose from in your area. The list includes doctors who specialize in family practice, internal medicine or pediatrics. Female members can choose an OB-GYN as their PCP. If you do not select a PCP, MHP Community will choose one for you. 

Can I change my PCP?

Yes. Please use the PCP Selection link on the website to request a PCP change or call Customer Service at (888) 327-0671, TTY 711. Customer Service can assist you with your request and verify if the PCP you have chosen is accepting new patients. Visit McLarenHealthPlan.org for the current provider directory. The PCP change will be effective the first day of the month following notification to MHP Community. You may start seeing your new PCP when the change becomes effective.

What does in-network mean?

In-network means the provider or facility has a contract with MHP Community. The provider or facility has agreed to provide services to you at a discounted rate, making in-network services your best cost-saving option.

What does out-of network mean?

An out-of-network provider or facility does not have a contract with MHP Community. They are paid at a reasonable and customary rate.* The out-of-network provider or facility can charge you the difference between what their total charged amount is and what MHP Community paid. This is called “balance billing.” Your deductible and coinsurance may be higher when you see an out-of-network provider.

*HMO Plan members only have out-of-network coverage for urgent and emergent care. All other out-of-network services are not covered unless preauthorized by MHP Community.

What is a copayment or copay?

A copayment is a fixed amount you pay for a health care service. It is usually paid directly to the provider when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

What is a deductible?

A deductible is the amount you are responsible to pay annually before MHP Community starts to pay. Services with a fixed dollar copay, such as office visits and preventive care, are not subject to deductibles. Services from out-of-network providers may result in higher deductibles. If you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network deductible amounts if you have an out-of-network benefit.

What is coinsurance?

Coinsurance is your share of the costs of certain health care services. It's figured as a percentage of the amount of MHP Community's reimbursement rate. You start paying coinsurance after you've paid your plan's deductible. If you have an out-of-network benefit, coinsurance amounts may be higher when you receive services from out-of-network providers, and if you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network coinsurance amounts

Can I get reimbursed if I pay out-of-pocket for services?

You should never have to pay out-of-pocket for anything other than your copay, coinsurance and/or deductible amounts if you receive covered services from an in-network provider. If you do pay out-of-pocket, only services that are covered by MHP Community will be reimbursed. You will need to provide a copy of your itemized statement, which includes CPT codes, diagnosis codes and charge amounts for each service. The statement should also include the provider’s name, address, phone, tax ID number and NPI number. You must also show proof of payment. Your request for reimbursement will be reviewed for medical necessity once we receive all of these items. Processing can take up to 60 days from the date received. MHP Community will only reimburse MHP Community's reimbursement rate.

Do I need a referral or authorization to see an in-network specialist?

You do not need a referral from your PCP to visit or receive treatment in the office of an in-network specialist.* We recommend that you continue to consult with your PCP who can help direct you to the most effective, high quality care, and oversee the ongoing coordination of your health. Some services require MHP Community preauthorization. Your PCP will work with MHP Community to start any necessary preauthorization process.

Preauthorization requests are subject to medical review by MHP Community. We will make an authorization decision and return the referral to the requesting practitioner.

Customer Service can assist you in obtaining pricing information for in-network covered services. This pricing information does not guarantee approval of a preauthorization request.

*The following in-network service still requires an authorization:

  • Injectable medications given in the office of an in-network specialist
  • What if I want to see an out-of network specialist?

    HMO Plans: With the exception of emergency services or urgent care, care received from an out-of-network provider requires MHP Community preauthorization. Only such services that are approved by MHP Community prior to receiving out-of-network care will be covered. You will receive a decision in writing from MHP Community with an explanation for the denial if a preauthorization is denied.

    POS Plans:Although you may self-refer to an out-of network specialist for services, some still require preauthorization by MHP Community in order to be covered. Check your Certificate of Coverage to identify which services require preauthorization. Those out-of-network services that require preauthorization must be approved by MHP Community prior to receiving care to be covered. You will receive a decision in writing from MHP Community with an explanation for the denial if a preauthorization is denied.

    All Plans:If you have any questions about referrals for specific services, including pricing or financial responsibility, please call Customer Service at (888) 327-0671, TTY 711.

    Why do I need a prior authorization for a medication?

    MHP Community has placed a prior authorization (PA) restriction on certain medications within the drug formularies. PA means the medication requires special approval before it will be considered for coverage by MHP Community. A medication may require a prior authorization due to safety concerns or to ensure a more cost-effective formulary alternative cannot be used. If a prescribing provider feels a medication that requires prior authorization is medically necessary, then a Prior Authorization Form should be completed by the prescribing provider and faxed to the number indicated on the form. Please contact Customer Service at (888) 327-0671 if you have any questions regarding the PA process or the status of a PA request.

    Note: Please contact Customer Service at (888) 327-0671, TTY 711, if you are in need of an emergency supply of a medication that requires prior authorization.

    Can I get my medication by mail order?

    Yes. You can use mail order to obtain a 90-day supply of brand name (non-specialty) medications delivered directly to your home through WellDyneRx. Mail order can be an efficient and cost-saving way to obtain brand name (non-specialty) drugs. You can:
    • Order refills for existing, unexpired mail-order prescriptions online
    • Receive refill reminders via e-mail
    • Check the status of your order online
    Please visit WellDyneRx's website at https://4d.welldynerx.com/4DPharmacy/ or call them at (855) 404-0972. If you are logging on to the WellDyneRx website for the first time, you will need to set up a user name and password.

    WellDyneRx
    P.O. Box 90369
    Lakeland, FL 33804-0369
    Phone: (855) 404-0972
    Fax: (877) 221-1259

    If you have specific questions regarding your mail order benefit, please call Customer Service at (888) 327-0671, TTY 711.

    What preventive services are covered in full with no copays or deductibles?

    Under the Affordable Care Act there are certain in-network preventive services that are covered at 100%. This means you would have no copay or deductible to pay for these services. Some examples are certain immunizations for children and adults, and screening mammograms. The federal government changes these requirements often. For information on current preventive services please visit Healthcare.gov at www.healthcare.gov/coverage/preventive-care-benefits/. You may also refer to your Certificate of Coverage or call Customer Service at (888) 327-0671, TTY 711.

    What is the email address for the Appeals Department?

    The email address for the Appeals Department is MHPAppeals@mclaren.org.

    How can I, as a Michigan Insurance Marketplace (Exchange) Individual plan member, pay my premium payment?

    Individual plan, first premium payment: If you enrolled for your individual plan on the Michigan Insurance Marketplace (Exchange), your application will not be complete until you make your first premium payment to MHP Community. The amount of your portion of the premium will be provided to you as you complete your application on HealthCare.gov. In most cases, this premium payment must be received by MHP Community within 30 days of your enrollment in order for your coverage to be effective. Your first premium payment can be mailed to either MHP Community's standard mailing address of P.O. Box 771983, Detroit, MI 48277-1983 or overnight mailing addresses using FedEx or USPS Overnight Priority to JP Morgan Chase-Lockbox Processing, Attn: McLaren Health Plan Community, Lockbox #771983, 9000 Haggerty Rd., Belleville, MI 48111. Or you can bring it to MHP Community at G-3245 Beecher Road, Flint, Michigan 48532.  

    What is the standard mailing address for Exchange payments?

    McLaren Health Plan Community
    P.O. BOX 771983
    Detroit, MI 48277-1983

    What is the overnight mailing address for the Exchange payments??

    PO BOX 771983
    DETROIT, MI 48277-1983

    What is the mailing address for the Exchange overnight lockbox?

    To send a payment to MHP Community overnight, it must be sent by FedEx or USPS Overnight Priority to:
    JP Morgan Chase-Lockbox Processing
    Attn: McLaren Health Plan Community
    Lockbox #771983
    9000 Haggerty Rd
    Belleville, MI 48111

    Can I call Customer Service about my husband, wife or children's account, claims or health information?

    Federal law prohibits our Customer Service representatives from disclosing Protected Health Information (PHI) for anyone over the age of 18 to anyone else. Additional privacy laws are in place for information regarding children between the ages of 14 and 18. However, your family member can allow you access to this information if they complete, sign and return an Authorization for Use and Disclosure of Protected Health Information form to MHP Community. You can locate this form at McLarenHealthPlan.org or contact Customer Service at (888) 327-0671, TTY 711, for further information.

    Medicaid FAQ's - click to expand

    What is a Primary Care Physician (PCP)?

    Your Primary Care Physician (PCP) is your main doctor. You choose a PCP from our list of doctors when you join McLaren Health Plan (MHP). You can choose a pediatrician, family practice or internal medicine doctor. Female members can choose an OB-GYN as their PCP. The name of your PCP will be on your ID card. It is your responsibility to see your PCP within 60 days of becoming an MHP member, even if you are not sick. It is a good idea to meet with your PCP to talk about your past medical history. When you do get sick, your PCP will know your important health information. Both your PCP and MHP are available by phone 24-hours a day to answer questions about your care. Our toll-free number is (888) 327-0671, TTY 711. Be sure to contact your PCP to find out his or her after-hours number.

    How do I change my PCP?

    Your PCP is a big part of your good health. If you decide to change PCPs, you will need to:

    • choose another PCP from the MHP Medicaid list of doctors
    • use the link on the member information page of our website or call Customer Service at (888) 327-0671, TTY 711, to let them know the PCP you have chosen
    Call Customer Service if you need help finding a new PCP..

    Are dental services covered?

    McLaren Health Plan does not cover dental care. You still may be covered because you qualify for Medicaid. Use your Medicaid ID card for these services. Talk to your local MDHHS office if you have questions.

    Can I get help to stop smoking?

    Yes. MHP covers medications to help you stop using tobacco. These include Nicotine gum, lozenges, patches, inhalers and nasal sprays. Other covered medications are Zyban® and Chantix.® You can get other tobacco cessation benefits, such as counseling services, to help you stop smoking. You also are entitled to a FREE stop smoking program. Call (800) 784-8669 to enroll. Talk to your doctor if you are ready to quit.

    Do I have copays for health care services?

    You should not be asked to pay for any authorized covered services. You do not have a copayment for covered services as an MHP member. Please call Customer Service at (888) 327-0671, TTY 711, if you get a bill for an authorized covered service.

    Can I get translation services if I don't speak English?

    We will help you get translation services. These include services for members who are deaf, hard of hearing or have speech problems. Member materials are available in other languages and formats.

    The MHP Medicaid provider directory will tell you if a provider speaks another language. It tells you if a doctor has completed cultural and linguistic training (CLAS). This information is listed by the doctor's name. Call Customer Service at (888) 327-0671, TTY 711 if you need help understanding written materials or need translation services.

    Do I need a referral or authorization to see a specialist?

    Sometimes no, sometimes yes. A referral is when your PCP tells you to see a specialist. This process helps your PCP know what is going on with you. There is no paperwork for you to fill out.

    An authorization is when your PCP must ask MHP for approval for services you need. Some of the time you need a written authorization before you get services. In some cases, you don’t. Your PCP knows when an authorization is needed and when it isn't. You do not need written authorization from your PCP to visit or get services from an in-network specialist.*

    You can get a second opinion from an in-network provider. Call us for help if you want a second opinion from an out-of-network provider. Call Customer Service at (888) 327-0671, TTY 711, if you have questions about a health care service that may need a referral or authorization. Any health care that you get must be medically necessary. You should talk to your PCP before seeing any specialist even if you don't need a referral.

    *The following in-network service needs an authorization:
    Injectable medications given in the office of an in-network specialist

    What health care services are covered?

    Services covered by McLaren Health Plan Medicaid*

    Ambulance and other emergency transportation when necessary
    Blood lead tests and follow-up
    Breast pumps
    Certified Nurse Midwife
    Certified Pediatric & Family Nurse Practitioner services
    Chiropractic services (up to 18 visits per calendar year, additional visits require preauthorization)
    Diagnostic services (lab, X-ray, other imaging)
    Durable Medical Equipment and supplies
    Emergency services, including transportation
    End Stage Renal Disease services
    Family planning
    **Habilitative services
    Health education
    Hearing and speech
    **Hearing aids
    Home health services
    Hospice services
    Intermittent or short-term restorative or rehabilitative services (in a nursing facility) up to 45 days
    Immunizations (shots)
    Inpatient hospital services
    Long Term Acute Hospital Services (LTACH)
    Maternal infant health program services
    Medically necessary weight reduction
    Mental health care
    Office visits to your doctor
    Orthotic services
    Out-of-state services, when authorized
    Outpatient hospital services
    Parenting and birthing classes
    Pharmacy services
    Podiatry
    Preventive services
    Prosthetic services
    Sexually Transmitted Infection (STI) treatment
    Restorative or rehabilitative services (in a place other than a nursing facility)
    Specialist visits with referrals
    Therapy services (speech, language, physical and occupational)
    Tobacco cessation treatment, including pharmaceutical and behavioral support
    Transplant services
    Transportation
    Vision services
    Well-child visits under age 2
    *All covered services must be medically necessary.
    **These services are not covered for members age 21 and older. These services are covered benefits for children under the age of 21.
    You can call Customer Service at (888) 327-0671, TTY 711, if you have questions about the above services. If you do not understand the limits, or if you are told something is not covered, please call Customer Service for more information.

    Is Urgent Care or Emergency Care covered?

    Urgent and emergency care are covered benefits. Emergency rooms are only for serious medical conditions. Call your PCP if you are unsure whether something is an emergency. Call 911 or go to the nearest hospital when you have an emergency or if your health would be in danger if you don’t see a doctor immediately. Authorization is not required for emergency services.

    How do I get help with transportation to and from medical services?

    Call Customer Service at (888) 327-0671, TTY 711, for non-emergency, medically necessary transportation. They can let you know about MHP’s transportation guidelines.

    We will need time to set up your ride. We need some important information from you to be able to arrange a ride for you.

    There is a special review process if transportation is needed outside of your county.

    It is important to remember to call MHP immediately to cancel your transportation if you cancel your doctor's appointment.

    Call 911 if you are having a medical emergency and need to go to the hospital.

    How do I get a prescription filled?

    Take your prescription to any pharmacy. MHP covers medicines under a "Common Drug Formulary" for MHP members.

    MHP worked with the Michigan Department of Health and Human Services to create the Common Drug Formulary. Your doctor knows about it. Ask him or her to use it when prescribing your medicines. Sometimes the medicine your doctor thinks is the best treatment for you is not on the Common Drug Formulary. We have a way to get those medicines for you.

    Your doctor can fill out a preauthorization request form for MHP to review. MHP will tell your doctor if the medicine request has been approved. Sometimes MHP will give yo

    ur doctor another choice of medicine to prescribe for you. Some of your medicines are covered by MHP and will not have a copayment. You may be prescribed some medicines that will be covered by Medicaid. Always take your MHP ID card and your Medicaid ID card with you to the pharmacy.

    Call your doctor or Customer Service at (888) 327-0671, TTY 711, if the pharmacy tells you your prescription is not covered.

    Are dental services covered?

    McLaren Health Plan does not cover dental care. You still may be covered because you qualify for Medicaid. Use your Medicaid ID card for these services. Talk to your local MDHHS office if you have questions.

    Healthy Michigan FAQ's - click to expand

    What is a Primary Care Physician (PCP)?

    Your Primary Care Physician (PCP) is your main doctor. You choose a PCP from our list of doctors when you join McLaren Health Plan (MHP). You can choose a pediatrician, family practice or internal medicine doctor. Female members may choose an OB-GYN as their PCP. The name of your PCP will be on your ID card. It is your responsibility to see your PCP within 60 days of becoming an MHP member, even if you are not sick. It is a good idea to meet with your PCP to talk about your past medical history. When you do get sick, your PCP will know your important health information. Both your PCP and MHP are available by phone 24-hours a day to answer questions about your care. Our toll-free number is (888) 327-0671, TTY 711. Be sure to contact your PCP to find out his or her after-hours number.

    How do I change my PCP?

    Your PCP is a big part of your good health. If you decide to change PCPs, you will need to:

    • choose another PCP from the MHP Medicaid list of doctors
    • use the link on the member information page of our website or call Customer Service at (888) 327-0671, TTY 711, to let them know the PCP you have chosen.

    Call Customer Service if you need help finding a new PCP.

    Do I need a referral or authorization to see a specialist?

    Sometimes no, sometimes yes. A referral is when your PCP tells you to see a specialist. This process helps your PCP know what is going on with you. There is no paperwork for you to fill out.

    An authorization is when your PCP must ask MHP for approval for services you need. Some of the time you need a written authorization before you get services. In some cases, you don't. Your PCP knows when an authorization is needed and when it isn't. You do not need written authorization from your PCP to visit or get services from an in-network specialist.*

    You can get a second opinion from an in-network provider. Call us for help if you want a second opinion from an out-of-network provider. Call Customer Service at (888) 327-0671, TTY 711, if you have questions about a health care service that may need a referral or authorization. Any health care that you get must be medically necessary. You should talk to your PCP before seeing any specialist even if you don't need a referral.

    *The following in-network service needs an authorization:
    Injectable medications given in the office of an in-network specialist

    What is a Health Risk Assessment (HRA)?

    An HRA is a survey about your health. This survey helps your PCP work with you to meet your health needs in the best way possible. The HRA is confidential and subject to your privacy rights. Every Healthy Michigan Plan member should complete an HRA every year. There are four sections on the HRA.

    • Section 1 has questions about your health and lifestyle
    • Section 2 is for you to complete about your PCP appointment
    • Section 3 includes questions about making changes
    • Section 4 is for your PCP to complete at your first appointment

    All MHP Healthy Michigan Plan members must complete an HRA. Call Customer Service at (888) 327-0671, TTY 711, to start your HRA today!.

    Do I have copays for health care services?

    The McLaren Healthy Michigan Plan has copays. Your copays will be payable to MHP through a special health care account called the MI Health Account. Copays will not be collected for the first six months after enrollment. The copays will be paid to MHP through your MI Health Account at a later date.

    The Healthy Michigan Plan requires those with annual incomes between 100 percent and 133 percent of the federal poverty level to contribute two percent of income annually for cost sharing purposes. You will get information about your MI Health Account and contributions for cost sharing from MHP. You can reduce your annual contribution and copays by participating in healthy behavior activities. Cost sharing cannot exceed five percent of your income.

    Not everyone is required to pay copays. Not all services have copays. For example, services that help you get or stay healthy may have no copays. This includes things like preventive services or certain services or medications that help you manage a chronic condition. Members under 21 have no copays.

    Your MI Health Account Statement will tell you what you must pay and how the amounts were figured. When you get your MI Health Statement, it is your responsibility to make your payments as listed on the statement. Call Customer Service at (888) 327-0671, TTY 711, if you have any questions regarding copays.

    What is a Health Risk Assessment (HRA)?

    An HRA is a survey about your health. This survey helps your PCP work with you to meet your health needs in the best way possible. The HRA is confidential and subject to your privacy rights. Every Healthy Michigan Plan member should complete an HRA every year. There are four sections on the HRA.

    • Section 1 has questions about your health and lifestyle
    • Section 2 is for you to complete about your PCP appointment
    • Section 3 includes questions about making changes
    • Section 4 is for your PCP to complete at your first appointment

    All MHP Healthy Michigan Plan members must complete an HRA. Call Customer Service at (888) 327-0671, TTY 711, to start your HRA today!.

    What health care services are covered?

    Services Covered by McLaren Healthy Michigan Plan*

    Ambulance and other emergency transportation when necessary
    Breast pumps
    Certified Nurse Midwife
    Certified pediatric and Family Nurse Practitioner services
    Chiropractic services (up to 18 visits per calendar year, additional visits require preauthorization)
    Dental services
    Diagnostic services (lab, X-ray, other imaging)
    Durable Medical Equipment and supplies
    Emergency services, including transportation
    End Stage Renal Disease services
    Family planning
    Habilitative services
    Health education
    Hearing and speech
    **Hearing aids
    Home health services
    Hospice services
    Intermittent or short-term restorative or rehabilitative services (in a nursing facility) up to 45 days
    Immunizations (shots)
    Inpatient hospital services
    Long Term Acute Hospital Services (LTACH)
    Maternal infant health program services
    Medically necessary weight reduction
    Mental health care
    Office visits to your provider
    Orthotic services
    Out of state services, when authorized
    Outpatient hospital services
    Parenting and birthing classes
    Pharmacy services
    Podiatry
    Preventive services
    Prosthetic services
    Sexually Transmitted Infection (STI) treatment
    Restorative or rehabilitative services (in a place other than a nursing facility)
    Specialist visits with referrals
    Therapy services (speech, language, physical and occupational)
    Tobacco cessation treatment, including pharmaceutical and behavioral support
    Transplant services
    Transportation
    Vision services
    *All covered services must be medically necessary.
    **Hearing aids are covered for members age 21 and over.
    You can call Customer Service at (888) 327-0671, TTY 711, if you have questions about the above services. If you do not understand the limits, or if you are told something is not covered, please call Customer Service for more information.

    Is Urgent Care or Emergency Care covered?

    Urgent and emergency care are covered benefits. Emergency rooms are only for serious medical conditions. Call your PCP if you are unsure whether something is an emergency. Call 911 or go to the nearest hospital when you have an emergency or if your health would be in danger if you don’t see a provider immediately. Authorization is not required for emergency services.

    How do I get help with transportation to and from medical services?

    Call Customer Service at (888) 327-0671, TTY 711, for non-emergency, medically necessary transportation. They can let you know about MHP's transportation guidelines.

    We will need time to set up your ride. We need some important information from you to be able to arrange a ride for you. There is a special review process if transportation is needed outside of your county.

    It is important to remember to call MHP immediately to cancel your transportation if you cancel your doctor's appointment.

    Call 911 if you are having a medical emergency and need to go to the hospital.

    Are dental services covered?

    McLaren Healthy Michigan Plan covers dental services for Healthy Michigan Plan members. Your dental coverage is through Delta Dental. If you have any questions about your dental coverage, please call Delta Dental at (866) 558-0280.

    Can I get help to stop smoking?

    Yes. MHP covers medications to help you stop using tobacco. These include Nicotine gum, lozenges, patches, inhalers, nasal sprays, Zyban® and Chantix.® You can get other tobacco cessation benefits, like counseling services, to help you stop smoking. You are also entitled to a FREE stop smoking program. Call (800) 784-8669 to enroll. Talk to your doctor if you are ready to quit.

    Is Urgent Care or Emergency Care covered?

    Urgent and emergency care are covered benefits. Emergency rooms are only for serious medical conditions. Call your PCP if you are unsure whether something is an emergency. Call 911 or go to the nearest hospital when you have an emergency or if your health would be in danger if you don’t see a provider immediately. Authorization is not required for emergency services.

    Can I get translation services for non-English speaking members?

    We will help you get translation services. This also includes services for members who are deaf, hard of hearing or have speech problems. Member materials are available in other languages and formats.

    The MHP provider directory will tell you if a provider speaks another language or if a doctor has completed cultural and linguistic training (CLAS). This information is listed by the doctor's name. Call Customer Service at (888) 327-0671, TTY 711, if you need help understanding written materials or need translation services.

    How do I get a prescription filled?

    Take your prescription to any pharmacy. MHP covers medications under a "Common Drug Formulary" for Healthy Michigan Plan members. MHP worked with the Michigan Department of Health and Human Services to create the Common Drug Formulary. Your doctor knows about it. Ask him or her to use it when prescribing your medicine.

    Sometimes the medicine your doctor thinks is the best treatment for you is not on the Common Drug Formulary. We have a way to get those medicines for you.

    Your doctor can fill out a preauthorization request form for MHP to review. MHP will tell your doctor if the medicine request has been approved. Sometimes MHP will give your doctor another choice of medicine to prescribe for you.

    Some of your medicines are covered by MHP and will not have a copayment. You may be prescribed some medicines that will be covered by Medicaid. Always take your MHP ID card and your Medicaid ID card with you to the pharmacy.

    Call your doctor or Customer Service at (888) 327-0671, TTY 711, if the pharmacy tells you your prescription is not covered.

    McLaren Health Advantage FAQ's - click to expand

    What is a Primary Care Physician (PCP)?

    Your PCP will work closely with you to coordinate your health care needs and send you to a specialist when it is medically necessary. Each family member covered by MHA must choose a PCP who is in our network. You can find the provider directory on our website at McLarenHealthAdvantage.org which will give you a list of doctors from which to choose. This list includes doctors who specialize in family practice, internal medicine or pediatrics. Women may choose an OB-GYN as their PCP.

    How do I change my PCP?

    Yes. The current provider directory is on our website at McLarenHealthAdvantage.org. Please use the PCP Selection link on the website to request a PCP change or call Customer Service at (888) 327-0671, TTY 711. They can assist you with your request and verify if the PCP you have chosen is accepting new patients. The change will be effective the first day of the month following notification to MHA.

    What does in-network mean?

    This means the provider and/or facility has a contract with MHA. The provider/facility has agreed to provide services to you at a discounted rate, making in-network services your best cost-saving option.

    What does specifically designated mean??

    A specifically designated provider is considered an out-of-network provider, but has an agreement with MHA not to "balance bill" members. If you see a specifically designated provider, you will be subject to your out-of-network deductibles and coinsurance amounts, which are higher than your in-network deductible and coinsurance amounts. The Affordable Care Act preventive services are not covered by out-of-network or specifically designated providers.

    What is a copayment or copay?

    A copayment is a fixed amount you pay for a health care service. It is usually paid directly to the provider when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled. Refer to your Schedule of Member Cost Sharing in your Benefit Booklet for more information.

    What is a deductible?

    A deductible is the amount you are responsible to pay annually before MHA starts to pay. Services from out-of-network providers may result in higher deductibles. If you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network deductible amounts. Refer to your Schedule of Member Cost Sharing in your Benefit Booklet for more information.

    What is coinsurance?

    Coinsurance is your share of the costs of certain health care services. It's figured as a percentage of the amount of MHA’s reimbursement rate. You start paying coinsurance after you've paid your plan's deductible. Coinsurance amounts may be higher when you receive services from out-of-network providers. If you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network coinsurance amounts. Refer to your Schedule of Member Cost Sharing in your Benefit Booklet for more information.

    Can I get reimbursed if I pay out-of-pocket for services??

    If you receive covered services from an in-network provider, you should never have to pay for anything other than your copay, coinsurance and/or deductible amounts. If you do pay out of pocket, only services that are covered by MHA will be reimbursed. You will need to provide a copy of your itemized statement, which includes CPT codes, diagnosis codes and charge amounts for each service. The statement should also include the provider’s name, address, phone, tax ID number and NPI number. You must also show proof of payment. Once we receive all of the above items, your request for reimbursement will be reviewed for medical necessity.  Processing can take up to 60 days from the date received. MHA will reimburse you at MHA's reimbursement rate, which may be less than the actual charge.

    Which preventive services are covered in full with no copays or deductibles?

    Under the Affordable Care Act, there are certain in-network preventive services that are covered at 100 percent, where you pay no copayments or deductibles.  A few examples are certain immunizations for children and adults and screening mammograms. The federal government changes these requirements often. For information on current preventive services, please visit www.healthcare.gov/coverage/preventive-care-benefits/. You may also refer to your Benefit Booklet or call Customer Service at (888) 327-0671, TTY 711.

    Are my bills for health care services coming directly from MHA?

    If you receive a statement showing a balance owed for medical services, the statement is coming directly from your provider. MHA does not bill you for your copays, coinsurance or deductible amounts. MHA does send you an Explanation of Benefits (EOB) that details the amount of charges for health care services you have received, the amount we paid, the amount we denied and any copay, coinsurance or deductible you may owe. If a bill from your provider does not match the information on your EOB, you can either call Customer Service at (888) 327-0671, TTY 711, for an explanation of the charge, or you can call your provider.

    Why do I need a prior authorization for medication?

    MHA has placed a prior authorization (PA) restriction on certain medications within the drug formularies. PA means the medication requires special approval before it will be considered for coverage by MHA. A medication may require a PA due to safety concerns or to ensure a more cost-effective formulary alternative cannot be used. If a prescribing provider feels a medication that requires a PA is medically necessary, then a Prior Authorization Form should be completed by the prescribing provider and faxed to the number indicated on the form. Please contact Customer Service at (888) 327-0671, TTY 711, if you have any questions regarding the PA process or the status of a PA request.

    Note: If you are in need of an emergency supply of a medication that requires prior authorization, please contact Customer Service at (888) 327-0671, TTY 711, for assistance.

    Can I get my medication by mail order?

    Yes. You can use mail order to obtain a 90-day supply of brand name (non-specialty) medications delivered directly to your home through WellDyneRx. Mail order can be an efficient and cost-saving way to obtain brand-name (non-specialty) drugs. You can order refills for existing, unexpired mail-order prescriptions online; receive refill reminders via email and check the status of your order online.

    Please visit WellDyneRx's website at https://4d.welldynerx.com/4DPharmacy/ or call them at (855) 404-0972. You will need to set up a user name and password the first time you log on to their website.

    WellDyneRx
    P.O. Box 90369
    Lakeland, FL 33804-0369
    Phone: (855) 404-0972
    Fax: (877) 221-1259

    Please call MHA Customer Service at (888) 327-0671, TTY 711, if you have specific questions regarding your mail order benefit.