FAQs For our Members

 

Community FAQ's - click to expand

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

When you join McLaren Health Plan, each family member who is covered must choose a PCP that is in McLaren Health Plan’s network (you can find the complete provider directory on our website (www.mclarenhealthplan.org/CommunityProviderDirectory). The provider directory will give you a large list of PCPs to choose from in your area. This list will include doctors who specialize in Family Practice, Internal Medicine and Pediatrics. Your PCP will work closely with you and coordinate your health care needs. Your PCP will assist in coordination of your care and sending you to a specialist when it is medically necessary. If you do not select a PCP McLaren Health Plan will choose one for you. 

Can I change my PCP?

If you need to change your PCP, please call Customer Service at (888) 327-0671. They can assist you with your request, and verify if the PCP you have chosen is accepting new patients. You may also visit our website at MclarenHealthPlan.org for the current provider directory. The change will be effective the first day of the month following notification to McLaren Health Plan. You may start seeing your new PCP when the change becomes effective.

What does "in-network" mean?

This means the Provider and/or Facility has a contract with McLaren Health Plan. The Provider/Facility has agreed to provide services to you at a discounted rate, making in-network services your most cost saving option.

What does "out-of network" mean?

An out-of-network Provider and/or Facility does not have a contract with McLaren Health Plan, and so they are paid at a reasonable and customary rate. The out-of-network Provider or Facility can charge you the difference between what they charged and what McLaren Health Plan paid.  This is called “balance billing”. In addition, your deductible and coinsurance may be higher when you see an out-of-network Provider.

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?

Your deductible is the amount you are responsible to pay annually before McLaren Health Plan starts to pay. Remember out-of-network deductibles may be higher.

What is coinsurance?

Coinsurance is your share of the costs of certain health care services. It's figured as a percentage of the amount McLaren Health Plan’s reimbursement rate. You start paying coinsurance after you've paid your plan's deductible. Once again, these costs are higher when you go out-of-network.

What if I pay out of pocket for services, can I get reimbursed?

If you receive covered services from an in-network provider you should never have to pay for anything other than your copay, coinsurance or deductible. If you pay out of pocket because you went out-of-network, only services that are covered by McLaren Health Plan 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 30 days from the date received.

Do I need a referral 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. It is recommended that you continue to consult with your PCP who can help direct you to the most effective, high quality care, and oversee ongoing coordination of your health. Some services, however, require McLaren Health Plan Preauthorization.  Your PCP will be responsible for working with McLaren Health Plan and starting any necessary Preauthorization process.

Preauthorization requests are subject to medical review by McLaren Health Plan who 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 authorization Preauthorization request.

What if I want to see an out-of-network specialist?

HMO and High Deductible members:  With the exception of emergency services or urgent care, care received from an out-of-network provider requires McLaren Health Plan Preauthorization. Only such services that are approved by McLaren Health Plan prior to receiving out-of-network care will be covered. If a Preauthorization is denied, you will receive a decision in writing from McLaren Health Plan with an explanation for the denial.

POS members: Although you may self-refer to an out-of network specialist for many services, some require Preauthorization by McLaren Health Plan 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 McLaren Health Plan prior to receiving care to be covered.  If a Preauthorization is denied, you will receive a decision in writing from McLaren Health Plan with an explanation for the denial.
All members:  If you have any questions about referrals for specific services, including pricing or financial responsibility, please call Customer Service at (888) 327-0671.

Why do I need a prior authorization for a medication?

Prior Authorization/Drug Exception Request "

McLaren Health Plan 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 McLaren Health Plan. 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, found on page 7, 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 should have questions regarding the PA process or the status of a PA request.

Note: If the member is in need of an emergency supply of a medication that requires prior authorization, please contact our Customer Service Department at (888) 327-0671 for assistance.

Can I get my medication by mail order?

McLaren Health Plan, through a partnership with WellDyneRx, is able to provide our members with an efficient and cost-saving way to obtain brand name (non-specialty) medications. Our members can use mail order to obtain a 90-day supply of brand name medications delivered directly to their homes.

Here are some additional features our members will receive when using mail order pharmacy:
  • Order refills for existing, unexpired mail-order prescriptions online
  • Receive refill reminders via e-mail
  • Check the status of your order online
To access the features indicated above, please visit WellDyneRx or contact them directly by phone 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
https://4d.welldynerx.com/4DPharmacy/

If you have specific questions regarding your mail order benefit, please call McLaren Health Plan at (888) 327-0671. .

Are my bills coming from MHP directly?>

If you receive a statement showing a balance owed for medical services, the statement is coming directly from your provider. McLaren Health Plan does not bill you for your copays, coinsurance and/or deductible. McLaren Health Plan does send you an Explanation of Benefits (EOB) that details the amount of charges for your health care services, 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 McLaren Health Plan customer service for an explanation of the charge, or you can call your provider.

What are considered preventative services that are covered 100%?

Under the “Affordable Care Act” there are certain in-network preventive services that are covered at 100%.  Examples are certain immunizations for children and adults and screening mammograms. The federal government changes these requirements often., for information on current preventive services For more information refer to your Certificate of Coverage,visit https://www.healthcare.gov/preventive-care-adults/ or call McLaren Health Plan Customer Service at (888) 327-0671..

Are travel vaccines covered benefits?

Immunizations for the purposes of travel are a covered benefit.

What is the email address for the Appeals Department?

What is the mailing address for Exchange payments?

PO BOX 771983
DETROIT, MI 48277-1983

What is the mailing address for the Exchange overnight lockbox?

Must be sent by FedEx or Overnight Priority—
JP MORGAN CHASE- LOCKBOX PROCESSING
ATTN: MCLAREN HEALTH PLAN COMMUNITY
LOCKBOX #771983
9000 HAGGERTY RD
BELLEVILLE MI 48111

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

Individual plans – first premium:  If you enrolled for your individual plan on the Michigan Insurance Marketplace (Exchange), your application will not be complete until you make your initial premium payment to McLaren Health Plan.  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 payment must be received by the Plan within 30 days of your enrollment in order for your coverage to be effective.  Your payment can be made by mailing your initial premium to either the McLaren Health Plan’s mailing address of overnight lockbox  (see addresses above) or you may bring it personally to the McLaren Health Plan office at G-3245 Beecher Road, Flint, Michigan.  If time permits, you may also arrange for payment to be made through EFT or ACH on-line bill pay through your bank account.

Individual plans – premiums other than first premium:  Your payment can be made by mailing your monthly coupon with payment to either the Detroit or overnight lockbox addresses (see above), through EFT or ACH online bill pay through your bank account.

Contact Customer Service at (888) 327-0671 for further information or if you have any questions.

Can I call Customer Service about my husband/wife/children’s account, claims, 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.  (Addition privacy laws apply for information for children between the ages of 14 and 18). Your family member can however allow you access to this information if they fill, sign and return an Authorization for use and Disclosure of Protected Health Information to McLaren Health Plan. You can locate this form on our website PHI Form or contact Customer Service at (888) 327-0671 for further information.

Medicaid FAQ's - click to expand

What is Medicaid?

Medicaid is a jointly funded, Federal-State health insurance program for low-income and needy people. It covers children, the aged, blind and/or disabled and other people who are eligible to receive federally assisted income maintenance payments.

How Do I Find Out if I’m Eligible?

Contact your local Department of Human Services (DHS) office to see if you are eligible. Applications for medical assistance can be completed at www.mibridges.michigan.gov.

How Do I Enroll?

You must call Michigan ENROLLS at 1-888-367-6557 to enroll in a Medicaid Health Plan. Michigan ENROLLS can answer questions you have about Medicaid benefits.

Why Choose McLaren Health Plan?

McLaren Health Plan Medicaid covers doctor visits, prescription drugs, well visits, children’s health services and much more. Free transportation is offered to and from medical visits. McLaren Health Plan Customer Service is available to answer your questions Monday through Friday from 8 a.m. to 5 p.m. Call (888) 327-0671.

Medicare FAQ's - click to expand

What is an HMO?

A Health Maintenance Organization with a network of doctors, hospitals and other providers you must use to get services. You may not go to doctors or providers that are not in the network except in an emergency.

Are there any deductibles?

$150.00 deductible for prescriptions only, no deductible on the medical plan.

Do I need a referral for an office visit with a specialist?

No, as long as the specialist is in network.

Can I go to a provider not in in the McLaren Medicare Network?

No, if you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You must obtain approval from McLaren Advantage prior to seeking the care, or the care may not be a covered benefit. In this situation, you will pay the same as you would pay if you got the care from a network provider.

What will I pay for Diabetic Supplies and Services?

  • Diabetes monitoring supplies: You pay nothing.
  • Diabetes self-management training: You pay nothing.
  • Therapeutic shoes or inserts: You pay nothing.

Who do I make my monthly Premium payment check out to and where do I send payment

Please make checks or money orders payable to McLaren Advantage (HMO)

Mail to the following address:
McLaren Health Plan
PO Box 771982
Detroit, MI 48277-1982

When is Open Enrollment?

• October 15th –December 7th, annually

Healthy Michigan FAQ's - click to expand

What is Healthy Michigan?

The Healthy Michigan Plan provides health care benefits to Michigan residents aged 19-64 at a low cost so more people can have health care coverage.

How Do I Find Out If I’m Eligible?

You are eligible for the Healthy Michigan Plan if you:

  • Make about $16,000 if you are single or have income of about $33,000 for a family of four (133% of the federal poverty level)
  • Do not qualify for or are not enrolled in Medicare
  • Do not qualify for or are not enrolled in other Medicaid programs
  • Are not pregnant at the time of application
  • Are a resident of the State of Michigan

How Do I Enroll?

You must call Michigan ENROLLS at 1-888-367-6557 to enroll in a Healthy Michigan Health Plan. Michigan ENROLLS can answer questions you have about Healthy Michigan benefits.

Why Choose McLaren Health Plan?

McLaren Health Plan Healthy Michigan covers doctor visits, prescription drugs, well visits, mammograms and much more. McLaren Health Plan Customer Service is available to answer your questions Monday through Friday from 8 a.m. to 5 p.m. Call (888) 327-0671.