Changes to Your Membership Information

Current information about you helps us serve you better. Have you recently changed your

• Name?
• Address?
• Medical coverage? (Received additional coverage through another plan)

If there has been a change let us know. Also, be sure to contact MIChild at (888) 988-6300. Remember, we want to stay in touch with you. Up-to-date information helps us communicate better with our members.

Your Rights Under Other Laws

Certain federal laws also give you rights or benefits. State laws also give you certain benefits. These laws require that GVHP and other managed care organizations meet certain conditions. They also say we must cover certain services. GVHP wants you to know that we follow the conditions of these laws. Sometimes these laws say we must tell you about benefit changes. We tell you about new laws or changes to your benefits through our Newsletter. You may also be informed by letter.

Here is some brief information about laws that affect your health care coverage.

Women’s Health & Cancer Act of 1998:. This is a federal law. It requires health plans that cover mastectomies (surgery for removal of the breast due to malignant breast tumors), to cover other aspects of treatment. The following services must be covered:

• Reconstruction of the breast on which a mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and any physical complications resulting from the mastectomy, including lymphedemas (swelling and fluid retention of the lymph nodes)

The law states that an appropriate care plan will be determined. This plan will be done in consultation between the GVHP member and her physician. Coverage levels are subject to the terms of your GHVP Certificate of Coverage. The law has been in effect since October 21, 1998.

Newborns & Mothers Health Protection Act of 1996:. This is a federal law. It requires certain lengths of stay for mothers and newborns. These are:

• 48-hour length of stay for normal vaginal deliveries (NSVDs)
• 96-hour length of stay for caesarian section (C-sections) deliveries

The required length of stay is for both mother and child. This means that a newborn child’s hospital stay could be longer than his or her mother’s stay. Or, the mother’s stay could be longer than the child’s. The attending physician may decide, after discussion with and agreement by the mother, to discharge mother and baby earlier than the required length of stay.

GVHP has never assigned length of stays. We have always worked with the attending physician (doctor who delivered your baby), and allowed length of stays as ordered by the doctor. We want you to know that we do meet the requirements of this law.

Well-Woman Examination and Routine Gynecological Care. This law allows a female member to directly go to an obstetrician/gynecologist (OB/GYN) for an annual well-woman examination and routine gynecological care. An OB/GYN is a medical specialist. They specialize in the areas of pregnancy, labor, delivery, and after-care. They also treat female illnesses and conditions.

An annual well-woman examination means a visit for a health exam or physical. Routine gynecological care means a pap, pelvic and breast examination. This is an annual benefit. In summary, this law allows:

• A female member may have an annual well woman visit and/or routine gynecological exam with an OB/GYN.
• This visit does not need a referral (authorization) if the visit is with an in-network (GVHP OB/GYN Panel) OB/GYN.
• The visit needs a referral (authorization) if the visit is not with an in-network OB/GYN.

For a listing of the GVHP OB/GYN Panel, call your GVHP Family Health Center. Or call GVHP Customer Service team at 616-949-2410 or 800-335-1977.

Diabetes Mandate Bill. This law began April 1, 2001. This law ensures that all diabetics have some coverage for their diabetic medical supplies through their insurance company. Grand Valley Health Plan will provide coverage for diabetic medical equipment and supplies. This includes items such as blood glucose monitors, test strips, and lancets. This equipment is covered under your Durable Medical Equipment benefit.

There are a few things to keep in mind in order to be eligible for this coverage.

• Grand Valley Health Plan does require that you have regularly scheduled appointments at your GVHP Family Health Center for your diabetic care.
• Grand Valley Health Plan also requires that you get all your diabetic equipment and supplies through your GVHP Family Health Center. When you need supplies call your GVHP Family Health Center.

If you have any questions call your GVHP Family Health Center. Or call GVHP Customer Service Team at 616-949-2410 or 800-335-1977.

CHANGING GVHP Family Health CenterS

As a GVHP member, you choose a GVHP Family Health Center. This is where you will receive your care. It is important that you receive your care from one GVHP Family Health Center team. Consistent care allows you and your GVHP Family Health Center team to develop a relationship. This leads to better care, satisfaction and communication.

We know, members from time to time may wish to change GVHP Family Health Centers. If you do, just ask for a GVHP Family Health Center Transfer Form. You can obtain a form at your current GVHP Family Health Center. Or, call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977. The GVHP Family Health Center Transfer Form can also be found on our website at www.gvhp.com.

REQUEST FOR YOUR MEDICAL RECORD

As a GVHP member, you may want a copy of your GVHP medical record. As a member, you are entitled to receive one (1) copy of your current medical record at no charge. If you want a second there will be a charge. Contact your GVHP Family Health Center or Customer Service for cost details.

CLAIMS AND YOUR EXPLANATION OF BENEFITS

As a GVHP member, you do not have to worry about a lot of “paperwork.” This is especially true for authorized and covered services. Specialists will bill GVHP directly for the services provided to you. Other health care providers, such as hospitals and ambulance providers, will also bill GVHP. You may receive a bill for non-covered or non-authorized services or benefits.

Sometimes Practitioners and providers will send you a “statement.” This statement tells you GVHP is being billed. Look over all statements from Practitioners and providers. If you have any questions about what you have received, call your GVHP Family Health Center or the GVHP Customer Service Team at 616-949-2410 or 800-335-1977.

REQUESTS FOR “SPECIAL SERVICES”:

The GVHP Medical Opinion Process

There are “special services" that need to be reviewed. This review is done by the Medical Director. Examples of “special services” are:

• Out-of-Area Care
• Off –label Prescriptions
• Requests for New Technology

There is a process for looking at these requests. It is called the GVHP Medical Opinion Process. Your GVHP Family Health Center Practitioner helps in this process. You only need to speak with him or her about treatment options. The GVHP Family Health Center Practitioner makes the request. He or she completes the “paperwork.” The GVHP Family Health Center then gives medical information to the Medical Director.

The Medical Director reviews the request. Sometimes more information is required. A GVHP Specialty Care Nurse might help get more information. A GVHP Family Health Center team member might help in getting information. A Customer Service Representative might also gather other information. This could involve researching clinical studies. It can also include contacting medical experts. The Medical Director might also talk with treating physicians. We want you to know that we investigate each Medical Opinion thoroughly.

If you have any questions about the Medical Opinion Process, call your GVHP Family Health Center. You may also call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977. You may ask to speak to the person who made the decision about your request. We are always available to answer your questions.

NEW TECHNOLOGY AND TREATMENT IN MEDICAL CARE

New advances in health care happen every day. Technology is changing rapidly. And, new medical treatments appear quickly. While some of this is good, it is important to know what works. It is also important to know what does not. GVHP wants to be sure the new technology and care is safe.

GVHP covers “generally accepted medical care.” This means there already is a body of scientific evidence that supports the care. If there is none, GVHP does not cover the care. We call this type of care experimental and investigational. That is, these are not considered “generally accepted” medical care. We also do not cover drugs and devices that are a part of experimental or investigational treatment. This also includes other procedures and services.

GVHP does, however, review new technology, as it becomes available. It looks at investigational or experimental treatments. We research and review current medical literature. We consult with physicians and medical experts. We do this in the interest of knowing what is available. We do this to know what might help our members.

What kinds of things do we look for when reviewing new treatments? We use the GVHP Framework for Clinical Effectiveness. This acts as a guide in our decision-making. It asks the following questions about new treatments:

• Is it recognized by a national body such as the National Institute of Health (NIH), the National Cancer Institute (NCI), the Food and Drug Administration (FDA), Center for Medicare and Medicaid Services (CMS)?
• Is it undergoing clinical trials or study?
• Can you only get it in an investigational setting?
• Is there published scientific evidence? Or peer reviewed trials to support its clinical effectiveness?

If you have any questions, call your GVHP Customer Service team at 616-949-2410 or 800-335-1977.

YOUR CUSTOMER SERVICE TEAM

For any questions, concerns or issues about GVHP, you can always call your GVHP Family Health Center. Your Patient Care Coordinator is your supporter on the team. She or he is available to answer your questions. He or she can help you with any concerns. These can be about GVHP or your health care. It can be about the services you have received.

You may also call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977. The GVHP Customer Service Team works in support of your GVHP Family Health Center. Located at the GVHP Corporate Office, the GVHP Customer Service Team helps you and your GVHP Family Health Center by supplying these additional services:

• Information on how GVHP works including benefits, processes and procedures
• Handling and maintaining member application and change forms
• Verifying member status and other eligibility information
• Handling member grievances and complaints
• Supporting GVHP service needs

GVHP Customer Service Team can be reached at 616-949-2410 or 800-335-1977.

HOW TO GET ANSWERS TO YOUR QUESTIONS

Do you have any other questions? Are there still things you do not understand? There are places to get answers your questions.

A great place to start is with the GVHP Web Page. Our web address is: www.gvhp.com.

If you have questions about your benefits, here are some places to get answers. Your GVHP MIChild Certificate of Coverage gives details about your benefits. For any questions about your coverage, call your GVHP Family Health Center. Or, call the GVHP Customer Service team at 616-949-2410 or 800-335-1977.

If you have questions about how GVHP works, here are some places to get answers. Your MIChild Member Handbook gives you more information about how your plan works. You can call your GVHP Family Health Center. Or call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977.

Have questions about claims? Here are some places to get answers. Call your GVHP Family Health Center. Or, call the Customer Services Team at 616-949-2410 or 800-335-1977.