Table of Contents Benefits summary ................................................................................................................................................... 3 Interpreter services ................................................................................................................................................. 4 MHS Health Wisconsin phone numbers ................................................................................................................. 4 Welcome ................................................................................................................................................................. 4 We want to hear from you ...................................................................................................................................... 4 Renew your health benefits .................................................................................................................................... 4 Communications from MHS Health Wisconsin ....................................................................................................... 5 Your ForwardHealth ID card .................................................................................................................................... 5 Primary care provider (PCP) .................................................................................................................................... 5 Provider network .................................................................................................................................................... 5 Emergency care ....................................................................................................................................................... 6 Urgent care .............................................................................................................................................................. 6 How to get medical care when you are away from home ...................................................................................... 7 Pregnant women and deliveries ............................................................................................................................. 7 Services covered by MHS Health Wisconsin ........................................................................................................... 7 Mental health and substance abuse services ......................................................................................................... 8 Family planning services ......................................................................................................................................... 8 Dental services ........................................................................................................................................................ 9 Dental emergencies............................................................................................................................................. 9 Health Check ........................................................................................................................................................... 9 Ambulance ............................................................................................................................................................ 10 Extra benefits with MHS Health Wisconsin ........................................................................................................... 10 Case management services ................................................................................................................................... 10 When you may be billed for services .................................................................................................................... 12 If you are billed...................................................................................................................................................... 12 Other insurance ..................................................................................................................................................... 12 If you move ............................................................................................................................................................ 12 Second medical opinion ........................................................................................................................................ 12 © 2016 Managed Health Services Insurance Corp. All rights reserved. Member Services: (888) 713-6180 www.mhswi.com Page 1 Provider credentials .............................................................................................................................................. 12 Fraud and abuse program ..................................................................................................................................... 13 Physician incentive plan ........................................................................................................................................ 13 HMO exceptions .................................................................................................................................................... 13 Living will or power of attorney for healthcare .................................................................................................... 13 Right to medical records ....................................................................................................................................... 13 MHS member advocates ....................................................................................................................................... 14 External advocate .................................................................................................................................................. 14 State of Wisconsin HMO Ombudsman Program ................................................................................................... 14 Complaints, grievances and appeals ..................................................................................................................... 14 Medical decisions .................................................................................................................................................. 15 New technology .................................................................................................................................................... 15 Member rights and responsibilities ...................................................................................................................... 15 Civil rights .............................................................................................................................................................. 15 Notice of privacy ................................................................................................................................................... 16 Uses and disclosures of your PHI ...................................................................................................................... 17 Verbal agreement to uses and disclosure of your PHI ...................................................................................... 20 Uses and disclosures of your PHI that require your written authorization ...................................................... 20 Your rights ......................................................................................................................................................... 22 Contact information .......................................................................................................................................... 22 Provider directory ................................................................................................................................................. 23 Hospitals ........................................................................................................................................................... 26 Urgent care facilities ......................................................................................................................................... 28 Primary care providers (PCPs) ........................................................................................................................... 30 Dental providers .............................................................................................................................................. 135 Vision care providers ....................................................................................................................................... 136 Mental health/substance abuse treatment .................................................................................................... 140 © 2016 Managed Health Services Insurance Corp. All rights reserved. Member Services: (888) 713-6180 www.mhswi.com Page 2 BENEFITS SUMMARY BadgerCare and SSI Medicaid Benefits Summary ________________________________________________________________ Services must be medically necessary. Services Standard & SSI Plan Co pay *Medication State drug list *$.50 - $3 Physician visits Full coverage MHS covers Inpatient hospital Full coverage MHS covers Outpatient hospital Full coverage MHS covers Emergency room Full coverage MHS covers Nursing home Full coverage MHS covers Physical therapy