McLaren Health Plan
Community Plans (Individual/Family Plans)

Federal law prohibits our Customer Service representatives from disclosing Protected Health Information (PHI) for anyone over the age of 18 to anyone else. Additional privacy laws are in place for information regarding children between the ages of 14 and 18. However, your family member can allow you access to this information if they complete, sign and return an Authorization for Use and Disclosure of Protected Health Information form to MHP Community. You can locate this form at McLarenHealthPlan.org or contact Customer Service at (888) 327-0671, TTY 711, for further information.

Yes. Please use the PCP Selection link on the website to request a PCP change or call Customer Service at (888) 327-0671, TTY 711. Customer Service can assist you with your request and verify if the PCP you have chosen is accepting new patients. Visit McLarenHealthPlan.org for the current provider directory.

You should never have to pay out-of-pocket for anything other than your copay, coinsurance and/or deductible amounts if you receive covered services from an in-network provider. If you do pay out-of-pocket, only services that are covered by MHP Community 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. Your request for reimbursement will be reviewed for medical necessity once we receive all of these items. Processing can take up to 60 days from the date received. MHP Community will only reimburse MHP Community's reimbursement rate.

Direct Member Reimbursement Form

You do not need a referral from your PCP to visit or receive treatment in the office of an in-network specialist.* We recommend that you continue to consult with your PCP who can help direct you to the most effective, high quality care, and oversee the ongoing coordination of your health. Some services require MHP Community preauthorization. Your PCP will work with MHP Community to start any necessary preauthorization process.

Preauthorization requests are subject to medical review by MHP Community. We 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 a preauthorization request.

*The following in-network service still requires an authorization:

• Injectable medications given in the office of an in-network specialist

Thank you for choosing McLaren Health Plan. You now have three ways to make your Premium Payments. Select your payment method from the options below.

Please note you cannot pay your medical bills via these options, only premium payments.

McLaren Health Plan Community – Individuals On/Off Exchange

• Make Payment Online: You can now make your premium payment by credit/debit card or e-check.
  
  
  • Member Portal
  • InstaMed
    
    
• Mail Payment To:

McLaren Health Plan Community
PO Box 771983
Detroit, MI 48277-1983

• Make a Direct Deposit:
  

You can do a direct deposit via the Electronic Funds Transfer (EFT).
Download the EFT Form

Learn more about Auto No-Fault PIP Qualified Coverage, contact your agent for specific questions related to selecting coverage. If you need information about your deductible and whether your coverage excludes auto accidents, call Customer Service at 888-327-0671, TTY 711.

In-network means the provider or facility has a contract with MHP Community. The provider or facility has agreed to provide services to you at a discounted rate, making in-network services your best cost-saving option.

An out-of-network provider or facility does not have a contract with MHP Community. They are paid at a reasonable and customary rate.* The out-of-network provider or facility can charge you the difference between what their total charged amount is and what MHP Community paid. This is called “balance billing.” Your deductible and coinsurance may be higher when you see an out-of-network provider.

*HMO Plan members only have out-of-network coverage for urgent and emergent care. All other out-of-network services are not covered unless preauthorized by MHP Community.

McLaren Health Plan Community must provide a grace period of three consecutive months for a member, who when failing to timely pay premiums, is receiving advance payments of the premium tax credit. During this grace period, McLaren Health Plan Community must:

1. Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period;
2. Notify the Office of Health and Human Services of the member’s non-payment; and,
3. Notify providers of the possibility for denied claims when the member is in the second and third months of the grace period.

If a member does not pay all outstanding premiums during this grace period, the member will be terminated as required by the Office of Health and Human Services.

HMO Plans: With the exception of emergency services or urgent care, care received from an out-of-network provider requires MHP Community preauthorization. Only such services that are approved by MHP Community prior to receiving out-of-network care will be covered. You will receive a decision in writing from MHP Community with an explanation for the denial if a preauthorization is denied.

POS Plans: Although you may self-refer to an out-of network specialist for services, some still require preauthorization by MHP Community 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 MHP Community prior to receiving care to be covered. You will receive a decision in writing from MHP Community with an explanation for the denial if a preauthorization is denied.

All Plans: If you have any questions about referrals for specific services, including pricing or financial responsibility, please call Customer Service at (888) 327-0671, TTY 711.

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.

A deductible is the amount you are responsible to pay annually before McLaren Health Advantage starts to pay. Services with a fixed dollar copay, such as office visits and preventive care, are not subject to deductibles. Services from out-of-network providers may result in higher deductibles. If you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network deductible amounts if you have an out-of-network benefit.

Coinsurance is your share of the costs of certain health care services. It's figured as a percentage of the amount of McLaren Health Advantage’s reimbursement rate. You start paying coinsurance after you've paid your plan's deductible. If you have an out-of-network benefit, coinsurance amounts may be higher when you receive services from out-of-network providers, and if you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network coinsurance amounts

The email address for the Appeals Department is MHPAppeals@mclaren.org.

Under the Affordable Care Act there are certain in-network preventive services that are covered at 100%. This means you would have no copay or deductible to pay for these services. Some examples are certain immunizations for children and adults, and screening mammograms. The federal government changes these requirements often. For information on current preventive services please visit Healthcare.gov. You may also refer to your Certificate of Coverage or call Customer Service at (888) 327-0671, TTY 711.

MHP Community 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 MHP Community. 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 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 have any questions regarding the PA process or the status of a PA request.

Note: Please contact Customer Service at (888) 327-0671, TTY 711, if you are in need of an emergency supply of a medication that requires prior authorization.

Your PCP is your main doctor and works closely with you to coordinate your health care needs. He or she will send you to a specialist when it is medically necessary. Each family member covered by MHP Community must choose a PCP in our network. You can find the provider directory at McLarenHealthPlan.org. The provider directory will give you a list of PCPs to choose from in your area. The list includes doctors who specialize in family practice, internal medicine or pediatrics. Female members can choose an OB-GYN as their PCP. If you do not select a PCP, MHP Community will choose one for you.