Introduction

When you joined GVHP, you joined a team. The team focuses entirely on managing your health care needs. Who are the team members? The team is GVHP, your GVHP Family Practice Office and you!

GVHP helps you understand your membership. We explain your rights and responsibilities. We help you understand your health care benefits. We listen to your concerns. We help you learn how to maintain a healthy life style and staying well.

Your GVHP Family Practice Office manages your health care needs. It also coordinates your care. You go to your GVHP Family Practice Office for your well or sick visits. Your GVHP Family Practice Office gives you periodic health exams. It arranges hospital care. Your GVHP Family Practice Office also arranges referrals to specialists when needed. It keeps your medical records up-to-date. Finally, your GVHP Family Practice Office tells you about your health situation.

You, too, have an important role on the team. First, you receive the maximum plan benefits by having all your medical services provided or arranged by your GVHP Family Practice Office. Then, you get the recommended preventive screening services and routine immunizations by visiting your GVHP Family Practice Office. Finally, you practice good nutrition, exercise regularly and follow safety habits.

When you join GVHP, you join a health delivery organization. This organization is dedicated to giving you what you need to be a satisfied member. Take the time to learn how you can be an informed health care consumer. Continue reading your GVHP Member Handbook

GVHP'S Team Approach To Health Care

GVHP is a health care delivery network. We deliver care through our network of health care practitioners and providers. More specifically, GVHP owns and operates several GVHP Family Practice Offices. This is one part of our unique delivery system. What are the other parts?

First, letÕs learn what a GVHP FAMILY PRACTICE OFFICE is. A GVHP Family Practice Office is much like any physician office. There are family practice doctors, physician assistants, nurse practitioners, and nurses on hand to help you. A GVHP Family Practice Office is much more than just a doctorÕs office! A GVHP Family Practice Office offers the services of other health care professionals. Counseling and Wellness staff, x-ray technicians, and pharmacy staff are other health care professionals you can find right at your GVHP Family Practice Offices. Your GVHP Family Practice Office is about customer-centered service and convenience.

GVHP identifies its physicians, nurse practitioners, and physician assistants as "PRACTITIONERS". This word comes from our accrediting body, the National Committee on Quality Assurance (NCQA). We will use this special word throughout this handbook.

Who's On Your Team?

Family Practice Physician

Family practice physicians are specialists in family medicine. They can handle the health care needs of your entire family. Family practice physicians may either be MDs (Medical Doctor) or DOs (Doctor of Osteopathy). Both have received similar training. They complete a residency program. This gives them training in important medical areas. They train in pediatrics, learning about children, their development and illnesses. They train in obstetrics, learning about pregnancy, labor, delivery and after-birth. They train in gynecology, learning about diseases relating to women. Their training includes internal medicine, the branch of medicine that studies the internal workings of the body. Finally, they train in community medicine and surgery. Family practice physicians are board-eligible or board-certified. Family practice is one of only a few medical specialties that requires recertification. Every six (6) years they must take and pass an exam.

Physician Assistants and Nurse Practitioners

Both physician assistants (PAs) and nurse practitioners (NPs) are medical professionals. We often call them mid-level practitioners, the PA and NP work under the supervision of a family practice physician. Both receive post-graduate training in fundamental medical and clinical sciences. PAs and NPs must meet exacting educational requirements as well as strict licensing standards. They must be board-certified. Just like a family physician, this happens every six (6) years. They are able to diagnose and treat most medical problems. Mid-level practitioners can manage the stable phases of chronic conditions such as high blood pressure and diabetes. They can write prescriptions and do health assessments and exams.

When you visit your GVHP Family Practice Office, you will most likely see both a family practice physician and a physician assistant PA) or nurse practitioner (NP). Who you see depends on your prefrence and your medical needs.

There are other health care professionals on your team. These professionals also are trained and licensed in their special health care area. They work in support of your "primary" health care needs. These professionals include. . .

Nursing Staff

Registered nurses (RNs) are part of GVHPÕs nursing staff. Licensed practical nurses (LPNs) and medical assistants (MAs) are also part of this staff. Each must complete a specific educational program and receive training. Their training allows them to take medical histories. They also learn how to monitor your blood pressure and draw blood samples. They receive training on immunizations and allergy injections. They also assist during routine examinations. Nursing staff also answer your health care questions over the phone. They are trained to assess your symptoms. They help make the right appointments for your needs.

Specialty Care Nurse

GVHP has a team of specialty care nurses. They are nurses who work on your behalf. The Specialty Care Nurse contacts you when you are in the hospital. She or he helps organize your care. She or he also arranges any special needs after you leave the hospital. The Specialty Care Nurse helps you understand your condition. This includes talking to you about treatment options and discussing your doctorsÕ recommendations. Finally, Specialty Care Nurses provide case management services for members with more complex medical conditions.

Health Counselor

Grand Valley Health Plan has counseling services available for you right at your GVHP Family Practice Office. Our Counseling & Wellness staff are called health counselors. They are specialists in helping you better manage and improve your overall health and well being. Health Counselors are part of your family practice team. They may even meet with you when you have an appointment with your doctor.

A Health Counselor is a person who is trained to provide coaching and counseling to you. This happens when you or your doctor think that things such as stress, worry, health habits or emotional concerns are affecting your physical or emotional well being. Health Counselors can also help you reduce symptoms or help you cope better with many chronic medical conditions. These conditions include things such as headaches, fibromyalgia, diabetes, asthma, and high blood pressure. Health Counselors can help develop plans for changing your behavior with things such as smoking, weight loss, alcohol use, exercise or other life style issues. Health Counselors can also help you deal with excess stress, depression, grief, anxiety and anger problems.

Health Counselors have a variety of backgrounds and training. Their training includes psychology, nutrition, health education, social work, nursing, exercise physiology and health counseling. In fact, all of our Health Counselors are trained Psychologists, Nutritionists, Social Workers, or Health Coaches with Masters degrees. They are all trained to work as part of your family practice team. This way you are sure to be treated as a whole person Ð your body, mind, and emotions all together.

Registered Pharmacist

GVHP operates its own pharmacies. GVHP pharmacies are staffed by registered pharmacists. The registered pharmacist supervises pharmaceutical and drug services at GVHP Family Practice Offices. In addition, he or she works closely with your GVHP Family Practice team. He or she is there to answer questions about your medication. All GVHP pharmacists are college educated and are licensed by the State of Michigan.

Your GVHP Family Practice team also has other staff working to help you with your Health Center appointment or referral needs. They strive to make this happen in a smooth and orderly manner. This staff includes . . .

Patient Care Coordinator

The Patient Care Coordinator is your advocate at the GVHP Family Practice Office. This means she or he works in support of your service needs. She or he is usually the first person you meet when you go the GVHP Family Practice Office. The Patient Care Coordinator schedules your appointments. She or he helps you understand your health professionals' instructions. She or he can also answer questions. And, she or he can help you with any concern you may have about health care or services.

Specialty Care Coordinator

The Specialty Care Coordinator helps you when you need a referral. This means if your GVHP Family Practice Office Practitioner and you decide you need to see a specialist, she or he arranges physician appointments. She or he also schedules tests as well as procedures and surgeries. She or he answers any questions you have about bills. Finally, the Specialty Care Coordinator answers questions about non-covered services. Non-covered services mean services that are not covered benefits under your GVHP Certificate of Coverage.

SO . . . . What does this all mean? This means your GVHP Family Practice Office team is here to give you and your family the best possible and most complete health care. We also are about quality care and service. The team approach helps us do this. We make sure the right person is doing the right thing at the right time and place, and remember YOU are part of the team!

Making Decisions About Your Health Care

GVHP believes your health care decisions are a shared responsibility. Who shares this responsibility? You, your family and health care professionals! Health care professionals must tell you about your health status. This includes giving you information about your medical condition and treatment options. You, in turn, must also tell us about your health history as well as on-going medical needs. If you want, your family can be included. They can give us other information to help us in treating you.

If you ask for a treatment or service that is unusual or rare, we might need to do some research. Your Health Care Practitioner can request an opinion from our Vice President of Medical Affairs (VPMA). The VPMA (otherwise know as the Medical Director) will look into your request. He or she will then recommend the best treatment option for you. What something costs is not as important as you getting better. We will recommend the type of care or plan that is proven to be the best way to help you get better. (See also Requests for "Special Services:" The GVHP Medical Opinion Process.)

When you picked GVHP, most likely you had to choose a new doctor. If you are currently getting care from another doctor, we will work with you to make sure your care is transferred without a problem. We will work with you to choose where you go and who provides your care. This happens based on your needs and our experience of where you can receive the best care. Your GVHP Family Practice Office team and you make the decision, not an insurance company.

Because you are a member of your health care team, we want you to be part of the decision process. To do this, your GVHP Family Practice Office team needs your attention. The more informed and involved you are in your own care, the better the care your GVHP Family Practice team can provide.

Recent studies link satisfaction with good communication. These studies show that communication means answering patientÕs questions or addressing concerns. Survey results show that satisfaction with a visit grows as this happens. These same studies also tell us that patients sometimes feel they are not understood. Patient confidence in health care professionals grows once they feel heard. Along with this, their satisfaction increases.

Your GVHP Family Practice Office visit is time limited. We want you to use this time wisely. You can do this by being prepared for your next visit. To help make your next visit the best one, we have put together a list of things to do.

1. Get ready for your office visit. Write down what you want to tell your GVHP Family Practice practitioner. For example, is anything unusual or abnormal? When did it start? What remedies did you try?
2. Write down what you want your GVHP Family Practice Office practitioner to do. For example, do you want pain relief? Tests? A referral? A prescription? Do you need help in figuring out what is wrong? Or, do you need reassurance about symptoms?
3. When you go to your appointment, pull out your "list" and share it!
4. Make sure your GVHP Family Practice Office practitioner is clear about what you said.
5. If a medical term or word is unclear, ask what it means.
6. When your health care practitioner says the "best option is . . ." Listen. Then, ask why? If you do not agree, tell your GVHP Family Practice practitioner. Ask if there are other options.
7. Ask specific questions. For example, "How long will it take to heal?" "What are the side effects?" or "How will this affect my daily activities?"
8. Tell your GVHP Family Practice practitioner you want to be an active member on your health care team.

If you are unhappy with your care for any reason, tell your GVHP Family Practice practitioner. He or she wants you to be satisfied. Changes cannot be made unless you are honest about what is bothering you. The stronger your relationship with your GVHP Family Practice team, the better care your team can give you. Get more out of your health care. Be involved! Be an active team member!

Finally, it is important that you understand that everything you need for care may not be covered. If you do not agree, it is your right to appeal through our grievance process. (See Member Grievances.)

Confidentality & Release of Information to Us

As a GVHP member, you have certain rights (see Your Rights and Responsibilities). One of these is the right to confidentiality. Confidentiality means you have the right to have your medical information kept private. This information cannot be given out without your permission. We at GVHP take confidentiality seriously.

When you join GVHP, you usually complete and sign the GVHP Membership Application and Change Form. When you do this, you agree to let us have access to your medical information. You also agree to let us use your medical information for certain business functions. This use is strictly limited.

So, what does this mean? It means you allow your GVHP Family Practice team to look at medical information. This means physician, hospital or other medical records. We use this information to give or arrange your care. You also allow GVHP to show your records. This happens when state or federal agencies or other organizations, such as NCQA, come to review GVHP. These regulatory groups review us to make sure we meet their standards and requirements. These groups license and regulate our business. We also need your information to pay or coordinate claims (see Coordination of Benefits and Subrogation) and to administer your benefits.

GVHP takes every precaution to keep all information confidential. We have strict procedures for maintaining your medical records. We will not release this information without your permission. How we keep your information protected and all of your privacy rights are listed in our GVHP Notice of Privacy Practices. You received a copy of the GVHP Notice of Privacy Practices in your New Member Packet when you enrolled with Grand Valley Health Plan. If you would like another free copy of this Notice of Privacy Practices please contact your GVHP Family Practice Office or Customer Services at (616) 949-2410 or download a copy from our website.

You may always look at your medical records during business hours. If you want a copy of your records, you will need to fill out a Release of Information Form. There might be a cost for copying your medical records. (See Requests for Your Medical Records.)

Please Note:
Children under 18 years of age also have certain rights to confidentiality. These rights come from state or federal laws. In special cases, this means we will not share any information, even with parents and guardians. Your son or daughter needs to sign a Release of Information if they want you to receive this information. What information is protected? Information on behavioral health, sexual activity or abuse and physical abuse situations are protected.

Your Grand Valley Health Plan Membership Card

Your membership or ID card is a key to medical services. It identifies you as a GVHP member.

Remember, always carry your membership card. Present this card whenever you receive medical or pharmacy services. This will help specialists, pharmacies, and hospitals know about your benefits and where to send bills.

If you are a new member and have not yet received your card, do not panic! You can use the "pink" copy of your GVHP Membership Change and Application Form until you receive your membership card. If you do not have your "pink" copy, call your Customer Service Team at (616) 949-2410.

Membership cards are issued to the subscriber. The subscriber is the person who is responsible for paying for GVHP coverage. The subscriber's spouse also gets a card. Both cards come in the name of the subscriber. GVHP does not send cards for other dependents. Dependents are persons covered under your GVHP plan. The subscriber membership or ID card will cover dependents. However, you may request a card for your child by calling the GVHP Customer Service Team at (616) 949-2410.

If you misplace or lose your card, or if the information on the front is incorrect, call your GVHP Family Practice or the GVHP corporate office at (616) 949-2410. GVHP will send you a new card.

GVHP processes membership card requests when they are received at our corporate office. It takes approximately 10 business days after we receive your request for a card to be issued.

There are two sides to your membership card. The front of the card gives information about your GVHP Family Practice Office. There is also information about your coverage or benefit level, and your prescription drug copayment (if you have one). The group number of your employer is listed on the card. The back side of the card gives you specific information about what to do in case of an emergency.

Grand Valley Health Plan Membership Card HMO GVHP Family Practice Office (1) Phone Number: (2) Subscriber: (3) ID#: (4) Coverage Code: (5) Group#: (6) Office Visit: (7) ER Copay: (8) Rx: (9) Med Center Copay: (10)

Contents of the Front of Your Card:

1. GVHP Family Practice Office: This is the name of your GVHP Family Practice Office.
2. Phone Number: This is the telephone number of your GVHP Family Practice Office. You may call this number 24 hours/day, 7 days a week.
3. Subscriber: This is the name of the card holder. Cards are issued in the name of the Subscriber.
4. ID #: This is your individual identification number.
5. Coverage Code: This tells you about your benefits.
6. Group #: This is the number GVHP has assigned for your employer
7. Office Visit: This lists any applicable office visit copayment
8. ER Copay: This lists applicable emergency room copay (copay is waived if admitted)
9. RX: This lists applicable prescription copayment amount. For example, RX5 means you have a $5 prescription copayment.
10. Med Center Copay: This lists applicable med center copayment. (This does not include the GVHP Urgent Care Center)

The Back of Your Card

The back of your card tells you what to do in case of an emergency. You will find the following information:

To the Member:

If you have a medical emergency, please call your Family Practice Office. However, if you believe the emergency may mean permanent damage to your health, go to the nearest emergency room. You or your representative should call your Family Practice Office within 48 hours or as soon as medically reasonable.

To the Hospital:

Local hospitals participate with GVHP. Out-of-area hospitalizations should be reported within 48 hours of admission.

To the Physician:

Contact the GVHP Family Practice Office on the front of this card to notify of an emergency admission or service. We request that this notification should occur within 48 hours.

Your Rights And Responsibilities

As a GVHP member, you have certain rights and responsibilities that are an important part of your health care. These fall under the Grand Valley Health Plan Member Bill of Rights and Responsibilities.

Your Rights

• The right to receive information about GVHP, its services, its practitioners and providers, and member rights and responsibilities.
• The right to have timely and appropriate medical care delivered in the appropriate setting.
• ¥ The right to be satisfied with your choice of GVHP Family Practice Offices and to have a choice within your health plan of practitioners and providers who meet high standards of professional training and experience.
• The right to be cared for by health care professionals who are accountable for the quality and confidentiality of the services they provide and for the satisfaction of their patients.
• The right to participate with your Health Care Team in decision making about your health care.
• The right to discuss appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
• The right to voice a complaint or appeal about GVHP or the health care provided.
• The right to be treated with respect and dignity and have your right to privacy maintained.
• The right to make recommendations regarding Grand Valley Health PlanÕs membersÕ rights and responsibilities policies.

Your Responsibilities

• The responsibility to hear how to use your GVHP Family Practice Office.
• The responsibility to call your primary GVHP Family Practice Office to get approval for any service.
• The responsibility to ask questions, when you think it is necessary, about your agreed upon treatment plan and then follow your treatment plan and the instructions you were given.
• The responsibility to ask questions to understand your health problems, participate in developing an agreed upon treatment plan and then follow your treatment plan and the instructions you were given.
• The responsibility to use the Helping You Help Yourself Handbook.
• The responsibility to be open and honest with your health care team and supply any information to the best of your ability that GVHP and our practitioners or providers need in order to provide you with care.
• The responsibility to understand your health problems and to participate with your health care team in developing agreed upon treatment goals.

Michigan Patient Protection Act

The Michigan Patient Protection Act is a law that began in October 1997. This law requires GVHP and other managed care plans to give members certain protections and information. Michigan is one of a few states leading the way to ensure consumer healthcare rights. GVHP supports and complies with the Michigan Patient Protection Act.

The Michigan Patient Protection Act guarantees you new rights. These are in addition to your GVHP Member Bill of Rights and Responsibilities. Some of these are:

• Getting information about GVHP participating practitioners and providers
• Getting health coverage sooner for problems that existed before you enrolled in your health plan. This is also covered under a federal law called the Health Insurance Patient Protection Act (HIPPA).
• Getting faster and clearer ways of handling complaints or grievances.

What information must GVHP share? We need to tell you about or how to get the following information and share with you why it is important to know. At GVHP we want to ensure that you have the resources available to assist you with any questions or concerns you have about either a GVHP practitioner, contracted facility or specialist. Referring to a facility that does a larger number of procedures makes sense. The more procedures the facility handles, the more experience they have. For complicated procedures this experience may contribute to improved outcomes:

Any questions about the Michigan Patient Protection Act, call your Customer Service Team at 616-949-2410.

Michigan Patient Advocate Law

Grand Valley Health Plan can also provide you with information about Advance Directives. Advance Directives is a written document in which you may give instructions about your health care that may be done sometime in the future if you lacked the ability to make a decision for yourself. Please contact your GVHP Family Practice Office or Customer Services at 616-949-2410 for more information about Advanced Directives.

Utilization Management Procedures

Grand Valley Health Plan is committed to providing necessary health care services to its members. To this end, GVHP encourages its practitioners to make appropriate medical decisions. This is providing utilization management, based on appropriate medical care and services.

Because of this, all Grand Valley Health Plan employees that make medical necessity determinations are aware of and practice consistent with the following GVHP policy:

• Utilization management decision-making is based only on appropriateness of medical care and service and existence of coverage.
• Grand Valley Health Plan does not provide its utilization review staff financial rewards or incentives for denying necessary services.
• Grand Valley Health Plan does not provide other incentives that would lead to inappropriate medical care or to not providing necessary services.

Grand Valley Health Plan also has many different utilization management procedures. These procedures outline how Grand Valley Health Plan makes decisions based on sound clinical evidence. These procedures include; primary care and secondary care management, pharmaceutical (If applicable),and counseling and wellness to name a few. If you are interested in receiving a copy of any of these utilization procedures please call Customer Service at (616) 949-2410.

Patient Safety Program For Grand Valley Health Plan

Grand Valley Health Plan is committed to improving patient safety as part of the healthcare delivery system by developing guidelines and benchmarks that meet basic physician, Member and employer needs and expectations. As part of this commitment, GVHP has joined the Michigan Inter-Plan Patient Safety Council to strengthen its ability to impact patient safety and work together with other participating health plan representatives. Our goal is to improve patient safety through development of a standardized approach. The focus includes development of a work plan that address the most current patient safety standards. If you would like a copy of GVHPÕs Patient Safety program and our annual evaluation please contact Customer Services at 616-949-2410.

Grand Valley Health Plan wants our Members to receive quality care in a safe setting. Choosing quality health care services for you and your family requires special thought and attention. GVHP directs Members to health care providers that have experience with your medical condition. These providers have had success and done a large number of procedures for your medical condition. These providers monitor and work to improve quality care. The Michigan Health and Safety Coalition collects this information on Michigan hospitals and produces guidelines for patient treatment for seven serious medical conditions. They also do this for the intensive care unit. To find more information on where West Michigan hospitals rank, visit www.mihelathandsafety.org or www.leapfroggroup.org.

Medication Safety

Understanding your medications is an important part of staying in charge of your health. The use of both prescription and over-the-counter medications requires careful attention regardless if you are at home or in the hospital.

These tips may help you make the most of your medication:

• Follow all of your physician's instructions about your medications. Read and follow any directions or warnings on over-the-counter medicines. If you have questions, remember to ask them before leaving the doctor's office or hospital.
• When you speak to your physician or pharmacist, ask as many questions as you need to feel confident, and be sure to tell him or her about any allergies you may have. If, when you receive your medication, it looks different, ask about it immediately and prior to taking it.
• If you see more than one doctor, be sure that each one is aware of all medicines that you take, including items such as Tylenol, laxatives, antihistamines, vitamins, and other over the counter products. If you have more than one doctor prescribing the same medicine, let them know immediately.
• At the pharmacy, check the label on the bottle or package. If it is not the same as before, ask why. Were you given the correct medicine? Make sure that you can read the instructions easily. If not, ask the pharmacist for a label thatÕs easier to read.
• Keep track of your medication with a chart listing the name, how much to take, when to take it, the doctor who prescribed it, and special directions such as Òtake with meals.Ó If you need help, ask your GVHP Family Practice Office.
• Use a pill "reminder" case that has compartments for each day of the week. These are available for purchase at the GVHP pharmacies as well as other drug stores. These compartments help you take your medicines correctly.
• You may experience side effects when you start a new medicine or after you have been taking it for some time. Call your physician immediately if you develop itching, swelling, dizziness, or any other ill effects.
• Don't stop taking your medication unless your doctor says to do so.
• If you skip a dose of medicine, donÕt assume itÕs safe to double the next dose. Check with your physician or pharmacist. Find out what to do before this happensÑthen add that information to your medication chart.
• If you mistakenly take an extra dose of medicine, call your physician or the Poison Control Center. Be prepared to tell them what medicine you took.
• When taking a prescription medicine, consult your physician before taking any other medicine. Some over-the-counter medicines may interfere with prescription medicines, while others may be safe.
• Remember that alcohol and medicine don't mix.
• In the hospital, ask questions about what medicines they are giving you. If the color or shape of the pill changes, ask questions before taking it.