Behavioral Health Care

GVHP offers a full range of Behavioral Health services. Behavioral Health is a term that covers mental health and substance abuse care. Most behavioral health services are provided right at your GVHP Family Practice Office and are part of the medical care that you receive. These services may include brief 10-15 minute appointments at the request of your doctor. Sometimes they may be a 20-30 minute appointment to assess your needs and develop a plan to help you.

Your benefit allows you twenty (20) outpatient mental health visits. This is a contract year benefit. (A contract year is a 12-month period during which you are covered. It usually begins with the effective date of your employer group or individual policy.) Most times you may only need to meet with a Wellness Counselor three or four times in order for you to improve your health and well being. Your counselor will let you know. As with your medical care, ask questions. Be involved.

Inpatient mental health care is only for the most serious psychiatric conditions. If you need this, you will be referred. Most hospitalizations are short. They usually last less than seven days. Most inpatient care occurs in a partial hospitalization program. This means you go to the hospital during the day and receive care. The care consists of half-day group and individual sessions. We know that being in the "least restrictive" environment is usually best for you and your family. This means you do not always need to be in the hospital. Another "level of care" can be just as effective. Inpatient mental health has been built into your base Certificate of Coverage. This additional benefit means that everyone has inpatient mental health coverage.

Your GVHP Wellness Counselor also provides alcohol and substance abuse services. As with mental health concerns, you will be evaluated. A plan will be developed if you need care. This will identify the best setting for your care. The Wellness Counselors are fully integrated with the GVHP Family Practice Office teams. This means that you can be assured all appropriate medical care is coordinated within your GVHP Family Practice Office team. Inpatient substance abuse services are also available. These services are used to stabilize a patientÕs condition. It can also be used for detoxification.

If you need more information about GVHP Behavioral Health services, call your GVHP Family Practice Office. Or, call your GVHP Customer Service team at 616-949-2410.

Referral Care

You and your GVHP Family Practice Office Practitioner may decide you need the services of a specialist. A specialist may sometimes be called a "referral physician." Your GVHP Family Practice Office Practitioner will refer you. You will go to a referral physician who participates with GVHP. This means the specialist is a member of the GVHP panel. Your condition might need the services of a specialty not available through our panel. In that case, you might be referred to a non-participating practitioner. Most importantly, you will be going to a referral physician we know can be trusted to give you the best care.

Your GVHP Family Practice Office helps you with your referral. The Specialty Care Coordinator will make your appointment. She or he will tell the referral physicianÕs office where to call for authorization of further services. The Specialty Care Coordinator will tell the specialistÕs office where to send the bills. Please remember if you have an office visit copayment, you owe this at the time of your specialist visit.

It is possible that the specialist might ask you to come back. Your GVHP Family Practice Office can only authorize services it has arranged. Do not schedule another appointment without first calling your GVHP Family Practice Office. Your GVHP Family Practice Office will tell you if the next visit is authorized. Be cautioned that if you go back without an authorization, you will be responsible for unauthorized visits or services.

Special Note: It is possible that your specialist may advise a service that is not a covered benefit. Your GVHP Family Practice Office Practitioner might also do this. The service or product might be medically necessary. However, if it is not a covered benefit, GVHP will not pay for it. You will be responsible for paying for it.

Hospital Care

If you need hospital care, your GVHP Family Practice Office Practitioner will make the arrangements. Or, a GVHP Specialty Care Nurse will help with this. You will go to the hospital that best fits your needs. GVHP participates with the following hospitals:

• Spectrum Blodgett Hospital
• St. Mary's Hospital
• Spectrum Butterworth Hospital
• Metropolitan Hospital

Your GVHP Family Practice Office physician is involved in your hospital care. He or she will work with the hospital staff to be sure you get the care that you need. A GVHP Specialty Care Nurse may also visit you in the hospital. She or he monitors your nursing care. She/he will set up any special needs you might have at home.

You might be asked to show your membership card when you go to the hospital. You should always carry your card. The hospital needs this information in order for you to be admitted. Bills for hospital care will go to GVHP. GVHP will pay benefits directly to the hospital.

GVHP has an agreement with United Resource Network. This agreement provides for non-experimental organ or tissue transplants at specific Centers of Excellence. These are the most outstanding places available for patients. We know that if our members go there, they can receive the highest quality medical care possible.

Case Management

GVHP is committed to providing high quality health services to our members. We offer case management services as part of this commitment.

What is case management? Case management is member-focused. It promotes quality. It is concerned about cost-effective care. It addresses a large range of individual needs across various levels of care. It is not just for a single episode of care. Finally, it is much more than discharge planning.

GVHP offers this free service to members with serious medical problems. These include cancer and diseases requiring transplants. Other complicated medical conditions receive case management services. These members usually have many problems and concerns that can "fall through the cracks." We do not want this to happen. ThatÕs why GVHP is committed to providing this important service.

Case management is also a process. It includes assessment and planning. Implementation and evaluation of your health care needs are also part of the process. A case manager works with you and your GVHP Family Practice Office team. She or he also involves referral physicians and providers. They are all part of your case management team. The case manager helps your team develop an individual treatment plan. This might include some of the following:

• Arranging and coordinating physician-directed treatment
• Assuring communication among all parties
• Finding and obtaining community-based resources that meet the memberÕs medical, psychological and social needs
• Keeping everyone on the team updated

Urgent Care

Urgent care involves medical care for conditions that are not life-threatening. This means your condition can wait for the time it would take to call your GVHP Family Practice Office for direction. An example of an urgent condition would be a sprained ankle. You are always eligible for urgent care when you are out-of-area due to travel or business. However, urgent conditions require a call to your GVHP Family Practice Office for authorization.

If you need urgent care services, please do the following steps:

1. Call your GVHP Family Practice Office at the telephone number on the front of your membership card.
2. If you are calling during regular business hours, you might be directed to your GVHP Family Practice Office for care. You may also be sent to the GVHP Urgent Care Center (UCC) if your GVHP Family Practice Office is not able to take care of you.
3. If you are calling after hours, someone will get back to you within fifteen (15) minutes of your call. You will be directed to the most appropriate setting.
4. Most likely you will go to our Urgent Care Center. Our UCC offers convenient and immediate care. You are less likely to wait to see a practitioner at our UCC than at one of the other local Med Centers.
5. If you are seen at our UCC, your office copayment applies (if you have one).
6. If you are directed or seen at a Med Center other than our UCC, then your Urgent Care copayment and any applicable deductible will apply.

The "reasonable prudent layperson" standard does not apply to urgent conditions. This means that you need your urgent care visit authorized by your GVHP Family Practice Office. If you go to an emergency room or Med Center for an unauthorized urgent care service visit, GVHP does not have to pay for this visit. You will be responsible for the cost of the services. See also Emergency Care below.

Our Urgent Care Center, located at 2680 Leonard NW, is open everyday, including weekends and Holidays.

Emergency Care

A medical emergency means you need attention right now! GVHP defines medical emergencies as an unexpected or unforseen onset of a traumatic bodily injury, life-threatening or disabling condition which, if not treated immediately, may result in serious physical impairment or loss of life.

Some examples of medical emergency include but are not limited to:

• Possible heart attack. You are having severe chest pain including sweating and/or nausea.
• Poisoning
• Convulsions
• Loss of consciousness
• Other acute medical conditions

If your condition is an emergency, go to the nearest hospital right away. Of, if you can, call your GVHP Family Practice Office for help. If you are unable to call before going, then call when medically possible or within 48 hours.

In case of an emergency, follow these steps:

• If you believe any delay in care will result in loss of life or permanent disablement, go to the nearest hospital emergency room or call 911.
• If you are not admitted, call your GVHP Family Practice Office when medically possible or within 48 hours.
• Do not go to the emergency room for follow-up care. Your GVHP Family Practice Office can provide this care or we will arrange for follow-up care. This includes on-going care. It does not matter what type of emergency it is.
• Present your GVHP membership card. Instructions about emergencies can be found on the back. (See Your Membership Card in this handbook.)

GVHP follows the reasonable prudent layperson standard for emergency care. A reasonable prudent layperson is a non-medical person. We ask the question: What would a reasonable prudent layperson do in a similar situation? GVHP pays for visits that meet the reasonable prudent layperson standard.

If you use an emergency room, you owe your Emergency Room copayment and any applicable deductible. If you are admitted that same day to the hospital, you do not owe the Emergency Room copayment. Observation stays still mean you owe the copayment. An observation stay means that you were never actually admitted to the hospital. You may have been there for less than 24 hours or you may not have been admitted by a physician. A physician must actually admit you to the hospital for your Emergency Room copayment to be waived. If you are transferred from a medical emergency room to a mental health hospital, you will still owe the Emergency Room copayment.

Remember, you are covered for emergency care if you are out-of-area, out-of-state or out-of-the-country. Copayments and any applicable deductibles still apply.

For more information, see your Certificate of Coverage, Article II: Emergency Care.

Pharmacy Services

Grand Valley Health Plan offers pharmacy services at all six (6) of our GVHP Family Practice Office locations. In addition, Grand Valley Health Plan offers two full-service pharmacies.

If you have prescription coverage, GVHP pharmacies offer you the following services:

• Prescriptions are filled at the time it is given to the GVHP pharmacist.
• The GVHP pharmacist will answer any questions or concerns at the time your prescription is filled.
• The GVHP pharmacist will explain how to take your medication. He/she can give you information about precautions or side effects.
• GVHP keeps a 90-day supply list of medications that can be given for one copayment. This service is limited to GVHP pharmacies only. Please note this list is subject to change from time to time. Please check with your practitioner for further information.
• Prescriptions can be mailed directly to your home at no extra charge. These prescriptions, however, must be prepaid. We accept credit and debit cards.
• If you have used all your refills, please call the GVHP pharmacy. They will call your Health Center practitioner and arrange additional refills.
• There are certain medications that can only be filled by a GVHP Pharmacy. Check with your practitioner for these special drugs.
• Our pharmacies maintain a limited number of over-the-counter products. These are offered for your convenience at very competitive prices. You might want to find out more about these.
• Contact a GVHP Pharmacy for special savings on prescriptions not covered by your benefits.

You may use the services of community pharmacies that participate with our managed care pharmacy network. This network is called MedImpact. To find out if your pharmacy is part of this network, simply ask your pharmacist.

Please remember if you have a prescription drug rider, you might owe a copayment. This is due at the time you pick up your prescription. Sorry, we cannot bill you later for this.

Your prescription will most likely be filled with a "generic" drug. A "generic" drug means a drug that has the same ingredients at the same doses as a brand name drug. If you want a brand name drug when a generic is available, you may request this. However, you will owe the difference between the cost of the generic drug and the brand name drug. This is in addition to your prescription drug copayment.

X-Ray and Laboratory Services

GVHP offers X-ray services. These services are available at conveniently located GVHP Family Practice Offices within the GVHP plan area.

GVHP also offers a full range of X-ray services at our Diagnostic Radiology Center located in the same building as the Beckwith GVHP Family Practice Office. The services provided by the Diagnostic Radiology Center include mammography, ultrasound, and x-ray services. You will find the GVHP Family Practice Office and the GVHP Diagnostic Radiology Center at 2680 Leonard NE, Grand Rapids, MI. This is right off the I-96 exit. Limited X-ray services are also available at our Wyoming Family Practice Office.

Your GVHP Family Practice Office has laboratory services available. The GVHP Family Practice Office is equipped to collect samples to send out for analysis. It also can perform basic laboratory tests like those for strep throat, pregnancy and basic urinalysis.

Call your GVHP Family Practice Office to arrange X-ray or laboratory services. Your Patient Care or Specialty Care Coordinator will help you. She/he will schedule or arrange all your service needs.

Ambulance Services

As a member of GVHP, you are covered for ambulance services. If you use an ambulance service, you have a $50 copayment. You will also owe any applicable deductible.

You may always call your GVHP Family Practice Office for help. GVHP Family Practice Office staff can be reached 24 hours a day and 7 days a week.

When you need an ambulance:

• Call an ambulance if the situation is life-threatening. You may also call 911.
• Call an ambulance if you are not physically able to go directly to the nearest hospital.
• Call an ambulance if you cannot take your family member safely to the nearest hospital.

Remember time will be lost when you call an ambulance. Time is lost as the ambulance travels to your location. In many cases, you can take the patient safely and quickly to the hospital.