Molina Healthcare Welcome to the Molina family. · Molina Healthcare has Customer Service staff that speaks English, Spanish, and Hmong. Interpreters are available for other languages

2400 S 102nd St. West Allis, WI 53227

1-888-999-2404www.MolinaHealthcare.com

Welcome to the Molina family.

Member Handbook and Provider DirectoryWisconsin | 2012 | Version 2

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Interpreter ServicesIf you need this printed material interpreted, need an alternative format (such as Braille, large print, or audio tape) or need assistance in using any of our services, please contact our Customer Service Department at 1-888-999-2404 for toll-free numbers or 414-847-1776 for local numbers.

2www.MolinaHealthcare.com Effective 02-2012

At Molina Healthcare, we have been helping mothers, children, families and seniors gain access to quality care for over three decades. We help patients navigate the healthcare system and build community partnerships to develop solutions to the challenges our members face. Molina’s history and member-focused approach began with the vision of Dr. C. David Molina, an emergency room doctor who saw people in need. Dr. Molina wanted to help, so he opened a community clinic where caring for people was more important than their ability to pay.

Today, Molina Healthcare serves the diverse needs of 1.6 million plan members and beneficiaries across the United States

through government-funded programs such as Medicaid, the Children’s Health Insurance Program (CHIP) and Medicare. Molina Healthcare also offers health information management and business process outsourcing solutions for state Medicaid programs

through its subsidiary, Molina Medicaid Solutions.

Molina provides NCQA-accredited care and services that focus on promoting health, wellness and improved patient outcomes. While Molina Healthcare continues to grow, we always put people first. We treat everyone like family, just as Dr. Molina did.

The Molina Healthcare Story

C. David Molina, M.D., MPH

Delivering Access to Quality Care Across Three Decades

Facts about Molina Healthcare• All of Molina Healthcare’s eligible health plans are accredited by the National

Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving healthcare quality. Molina’s eight NCQA accredited health plans place Molina Healthcare among the national leaders in quality Medicaid accreditations. Molina Healthcare of Missouri is currently preparing for NCQA accreditation review.

• For six years in a row, Molina Healthcare plans have been ranked among America’s top 100 Medicaid health plans by NCQA.

• Molina Healthcare was established by a physician and today remains a physician-led organization.

• Molina Healthcare is a leader in establishing Cultural and Linguistics Services programs that help medical practitioners and employees understand how patients’ cultural backgrounds affect their approach to healthcare.

• Molina Healthcare is committed to community service and has established a vibrant corporate social responsibility initiative to support the communities we serve. The Molina Helping Hands community volunteer program and Molina’s Community Champions Awards recognize and affirm the contributions of everyday community heroes.


Table Of ContentsWelcome to Molina Healthcare .....................................................................................................................................................4

Section 1- Member HandbookInTrOduCTIOnImportant Telephone Numbers....................................................................................................................................................5Selecting a Primary Provider (PCP) ............................................................................................................................................6ForwardHealth Card .....................................................................................................................................................................624 Hour Nurse Advice ..................................................................................................................................................................6

GeTTInG CarePrimary Care Provider (PCP) ......................................................................................................................................................7Making an Appointment With Your Doctor ...............................................................................................................................7Changing Your Doctor ..................................................................................................................................................................7Missed Appointments ...................................................................................................................................................................7All Doctor Visits ............................................................................................................................................................................8Emergency Care ............................................................................................................................................................................8Emergency Care from A Non-Molina Healthcare Provider .......................................................................................................8How to Get Medical Care When You Are Away From Home .....................................................................................................9Urgent Care ...................................................................................................................................................................................9Mental Health and Substance Abuse Services.......................................................................... ................................................10Pregnant Women and Deliveries ................................................................................................................................................10Other Insurance Coverage ..........................................................................................................................................................10When You May Be Billed For Services .......................................................................................................................................11

BenefITSServices Covered By Molina Healthcare ....................................................................................................... 12, 13, 14, 15, 16,17Family Planning Services ............................................................................................................................................................18HealthCheck ................................................................................................................................................................................18Dental Services ............................................................................................................................................................................19Ambulance ..................................................................................................................................................................................20Chiropractic Services ..................................................................................................................................................................20Transportation ............................................................................................................................................................................20Pharmacy Benefits .......................................................................................................................................................................21Care Evaluation ...........................................................................................................................................................................21Comprehensive Physical Exam ...................................................................................................................................................21

ServICeSQuality Improvement Program ..................................................................................................................................................22If You Move .................................................................................................................................................................................22HMO Exemptions .......................................................................................................................................................................22Living Will or Power of Attorney for Health Care ....................................................................................................................22Right to Medical Records ............................................................................................................................................................23Second Medical Opinions ...........................................................................................................................................................23Molina Healthcare’s Member Advocate .....................................................................................................................................23External Advocate .......................................................................................................................................................................23State Of Wisconsin HMO OMBUDS Program .........................................................................................................................23Physician Incentive Plan .............................................................................................................................................................23Provider Credentials ...................................................................................................................................................................23Member Rights ............................................................................................................................................................................24Complaints, Grievances and Appeals .........................................................................................................................................24Fair Hearings ...............................................................................................................................................................................25How Can I Stop Health Care Fraud? ..........................................................................................................................................25Your Civil Rights .........................................................................................................................................................................26Privacy Notice ........................................................................................................................................................... 27, 28, 29, 30

Section 2 - Provider directoryHospitals .......................................................................................................................................................................................31 Urgent Care ............................................................................................................................................................................ 32-33Dental Clinics ......................................................................................................................................................................... 34-36Primary Care Providers ......................................................................................................................................................... 37-87Specialty Care Providers ...................................................................................................................................................... 88-204


Welcome to Molina HealthcareThank you for choosing Molina Healthcare as your Health Maintenance Organization (HMO). Molina looks forward to serving you and keeping you healthy. This is your handbook. Please read it carefully. The handbook will help you understand your coverage with Molina Healthcare, and how to use our services. Your handbook has information that you and your family need to know. This handbook is for all members of Molina Healthcare. As a member of Molina Healthcare, you will receive all your health care from Molina Healthcare doctors and hospitals.

Molina Healthcare has Customer Service staff that speaks English, Spanish, and Hmong. Interpreters are available for other languages. Please feel free to call Customer Service at 1-888-999-2404 or 414-847-1776 if you have questions or if you need an interpreter. Molina has a TDD/TTY (hearing impaired) line at 414-847-1779.

The first things you should do are:

1. Read your handbook carefully. 2. Select the Primary Care Provider (PCP) that you and your children would like to have. 3. Put your handbook in a place where you can refer to it quickly.


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Important Telephone numbersCustomer Service Our regular Customer Service hours are 8:00 am to 5:00 pm Monday through Friday 1-888-999-2404 414-847-1776

Nurse Advice Line We are available 24 hours a day, seven (7) days a week. Our nurses can answer questions that you have about your health. For example, you can call if you have a health care question after your provider’s normal business hours or when your child is sick and you are not sure what to do. You can call if you have a follow up question after a medical appointment or if you are not sure where to go for care. The phone lines are staffed by registered nurses. Call 1-888-275-8750, Español 1-866-648-3537. For the hearing impaired, please call TTY / 1-800-688-4889, Español TTY / 1-866-833-4703.

Mental Health, Substance Abuse Services 1-877-491-0322 Beacon Health Strategies

Dental Services - BadgerCare Plus and Medicaid SSI Members Only in the following counties: Milwaukee, Waukesha, Racine, Kenosha, Washington, and Ozaukee 1-888-307-6563 DentaQuest

Vision Care 414-760-7400 If calling outside the 414 area code please call 1-800-822-7228 (for members who live outside of Milwaukee County).

Transportation Assistance for Health Care For transportation, please call Customer Service at 1-999-888-2404. A Customer Service Representative will schedule a ride for you.

Member Advocate 1-888-999-2404 414-847-1776

TDD/TTY (Hearing Impaired) After Hours and Weekends – Please call our Nurse Advice Line English TTY/ 1-800-688-4889 Español TTY/ 1-866-833-4703

Enrollment Specialist 1-800-291-2002

BadgerCare Plus or Medicaid SSI Pharmacy Member Services 1-800-362-3002

Molina Care Management Department 1-888-999-2404 • 414-847-1776


5

Selecting a Primary Care Physician (PCP) • Your PCP is the doctor who will manage all your health care. Every person must have a

PCP. You can choose your PCP from those available in the Provider Directory section of this book.

After you have selected the doctor, you and your children would like to have as your Primary Care Physician, fill out the PRIMARY CARE PHYSICIAN (PCP) SELECTION FORM that is included in this mailing. Mail it in the envelope provided. You will not need a stamp. NOTE: Racine County members should not use this form. If you are a Racine County member, please call (262) 687-2606 to select your PCP. If you need help choosing a doctor please call our Customer Service Department at (414) 847-1776 or 1- 888-999-2404. Please note the following important items:

• Contact your PCP for all medical care. • If you are not an established patient with your selected doctor, it is best to make a

routine health appointment as soon as possible. • Don’t forget to schedule a HealthCheck with your child or children’s PCP. • Use the emergency room only for true emergencies. • Carry your Forward or Forward Health ID card with you at all times. Show your card

whenever you receive medical care. • There are two different plans.

Forward Health or Forward ID Card Always carry your Forward Health or Forward ID card with you and show it every time you get care. You may have problems getting care or prescriptions if you do not have your Forward Health or Forward ID card with you. Also, bring any other health insurance cards you may have. Remember to always give health care providers your Forward Health or Forward ID card.

Selecting a Primary Care Provider (PCP)Every person must have a PCP. You can choose your PCP from those available in the Provider Directory section of this book. A PCP can be a doctor or a nurse practitioner.

After you have selected a doctor that you and your children would like to have as your Primary Care Provider, fill out the PRIMARY CARE PROVIDER (PCP) SELECTION FORM that is included in this mailing. Mail it in the envelope provided. You will not need a stamp.

NOTE: Racine County members who are assigned to or chose All Saints need to call 1-262-687-2778 to select a PCP. If you would like to choose a different provider please call us at 1-888-999-2404.

If you need help choosing a doctor please call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

Please note the following important items: • Contact your PCP for all medical care. • If you are not an established patient with your selected doctor, it is best to make a routine health appointment

as soon as possible.• Do not forget to schedule a HealthCheck with your child or children’s PCP. • Use the emergency room only for true emergencies.

forwardHealth Id CardAlways carry your ForwardHealth card with you and show it every time you get care. You may have problems getting care or prescriptions if you do not have your ForwardHealth card with you. Also, bring any other health insurance cards you may have. Remember to always give health care providers your ForwardHealth card.

24 Hour nurse advice LineMolina Healthcare’s Nurse Advice Line is available 24 hours a day, 7 days a week to answer your questions that you have about your health. For example, you can call: • If you have a medical question after your primary care provider’s normal business hours. • When your child is sick and you aren’t sure what to do. • If you have a follow-up question after a medical appointment. • If you are not sure where to go for care.

The phone lines are staffed by registered nurses. Many of the nurses are fluent in both English and other languages.

You can call Molina’s 24- Hour Nurse Line at 1-888-275-8750, Español 1-866-648-3537. For the hearing impaired, please call TTY/ 1-800-688-4889, Español TTY / 1-866-833-4703.


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Primary Care Provider (PCP)It is important to call your PCP first when you need care. Your PCP will manage all your health care. If you think you need to see another doctor or a specialist, ask your PCP. Your PCP will help you decide if you need to see another doctor.

You can choose your PCP from those available. NOTE: For women, you may also see a women’s health specialist (for example an OB/GYN doctor or a nurse midwife), in addition to choosing your PCP. There are HMO doctors who are sensitive to the needs of many cultures.

To choose a PCP, or change to a different PCP, call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

If you are a Racine County member and chose All Saints as your provider group, please call 1-262-687-2778 to select your PCP. If you choose not to continue with this provider group please call 1-888-999-2404 to select a PCP.

There may be copays when you see your doctor if you are covered under the BadgerCare Plus Benchmark Plan, BadgerCare Plus Standard Plan, or Core Plan.

Making an appointment with Your doctorOnce you are a member of Molina Healthcare, you can start seeing your doctor right away. If you have not picked a doctor or clinic yet, call Customer Service at 1-888-999-2404 or 414-847-1776.

Changing Your doctor If you are unhappy with the doctor you are seeing, you can pick a different doctor at anytime. Call Customer Service at 1-888-999-2404 or 414-847-1776, and we will help you choose a new doctor.

Missed appointmentsIt is important that you and your family keep all your health care appointments. If you are not able to keep the appointment, call your doctor’s office and let them know as soon as possible. Otherwise, the provider may refuse to schedule future appointments.


all doctor visits

BadgerCare Plus and Medicaid SSIService & Copays Standard Plan SSI Benchmark Plan BadgerCare Plus Core PlanOffice Visit – PCP $1 $0 $15.00 $0

Office Visit – Specialist $1 $0 $15.00 $0

Nurse Practitioner Services $1 $0 $15.00 $0

Chiropractic Services – is covered directly by the Wisconsin Medicaid Program not Molina Healthcare. You can receive these services from any chiropractor who will accept your ForwardHealth card.

$0.50 to $3 copayment per

service.$0 $15.00

Full coverage as of July 1, 2009. $0.50 to $3 copayment per

service.

Podiatry Services $1 $0 $15.00 $0

Immunizations $0 $0 $0 $0

HealthChecks up to age 21$0 $0 $0

Does not apply to Core Plan members

Any Pregnancy Related Visit

$0 $0 $0

Not Covered. Call us at 888-999-2404 right away if you are pregnant and we will help

you change to another program that will cover pregnancy.

emergency CareEmergency care is care that is needed right away. This may be caused by an injury or sudden illness. Some examples of emergency care are:

• Choking • Severe or unusual bleeding • Severe pain • Trouble breathing • Suspected poisoning • Severe burns • Serious broken bones • Suspected heart attack • Prolonged or repeated seizures • Unconsciousness • Suspected stroke • Convulsions

If you need emergency care, go to a Molina Healthcare provider for help if you can. BUT, if the emergency is severe, go to the nearest provider (hospital, doctor, or clinic). You may want to call 911 or your local police or fire department emergency services if the emergency is severe.

Remember, hospital emergency rooms are for true emergencies only. Call your doctor or our 24-hour Nurse Line at 1-888-275-8750 before you go to the emergency room, unless your emergency is severe.

emergency Care from a non-Molina Healthcare ProviderIf you must go to a hospital or provider that is not listed in your provider directory, call Molina Healthcare at 1-888-999-2404 or 414-847-1776 as soon as you can and tell us what happened. This is important so we can help you get follow up care.


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BadgerCare Plus and Medicaid SSIService & Copays Standard

PlanSSI Benchmark

PlanBadgerCare Plus Core Plan

Emergency Room Services

$0 $0 $60.00 per visit only if not

admitted to the hospital

No copayment per visit for memberswith income up to 100% FPL.

$60.00 copayment per visit formembers with income from 100% to 200% FPL (only if not admitted to the hospital)

Urgent Care Services $0 $0 $15.00 $0

How to Get Medical Care When You are away from HomeFollow these rules if you need medical care but are too far away from home to go to your assigned PCP or clinic. • For severe emergencies, go to the nearest hospital, clinic, or doctor. • For urgent or routine care away from home, you must get approval from us to go to a different doctor,

clinic or hospital. This includes children who are spending time away from home with a parent or relative. Call us at 1-888-999-2404 for approval to go to a different doctor, clinic, or hospital.

urgent CareUrgent care is care you need sooner than a routine doctor’s visit. Urgent care is not emergency care. Do not go to a hospital emergency room for urgent care unless your doctor tells you to go there.

Some examples of urgent care are:• Most broken bones • Non-severe bleeding • Bruises or sprains • Minor cuts • Minor burns • Most drug reactions

• If you need urgent care, call Customer Service at 1-888-999-2404 or 414-847-1776. We will tell you where you can get care.

• Please see the list of Urgent Care centers at the back of this book for a location near you.• You must get urgent care from Molina Healthcare doctors unless you get our approval to see a non-Molina

Healthcare doctor.

As a Molina member, you can call our Nurse Advice Line and talk with a nurse 24 hours a day, 7 days a week. Our nurses can answer questions that you have about your health. For example, you can call if you have a health care question after your provider’s normal business hours or when your child is sick and you are not sure what to do. You can call if you have a follow up question after a medical appointment or if you are not sure where to go for care. The phone lines are staffed by registered nurses. Call 1-888-275-8750, Español 1-866-648-3537. For the hearing impaired, please call TTY/ 1-800-688-4889, Español TTY / 1-866-833-4703.

Remember: Do not go to a hospital emergency room for urgent care unless you get approval from Molina Healthcare first.


Mental Health and Substance abuse ServicesMolina Healthcare partners with Beacon Health Strategies (Beacon) for mental health and substance abuse services. Our job is to help you. We help you make sure that you get the help you need by finding you the right doctor and therapist. If you need these services, please call Beacon Health Strategies at 1-877-491-0322. BadgerCare Plus Core Plan members only have coverage for services provided by a psychiatrist.

Pregnant Women and deliveriesIf you become pregnant, please let Molina and your county Human Services department know right away. This is to make sure you get the extra care you need. You may also not have copays when you are pregnant.

You must go to a Molina Healthcare hospital to have your baby. Talk to your Molina Healthcare doctor to make sure you understand which hospital you are to go to when it’s time to have your baby.

Also, talk to your doctor if you plan to travel in your last month of pregnancy. We want you to have a healthy birth and a good birthing experience; it may not be a good time for you and your unborn child to be traveling. We want you to have a healthy birth and your Molina Healthcare doctor knows your history and is the best doctor to help you have a healthy birth.

Do not go out of area to have your baby unless you have approval from Molina Healthcare.

You may also wish to pick a doctor for your child before you give birth. We will be able to help you pick a doctor for your unborn child.

IMPORTANT MESSAGE FOR CORE PLAN MEMBERS: You do not have any benefits for pregnancy. If you are pregnant or become pregnant call us right away at 1-888-999-2404! We will help you change to another program that will cover your pregnancy.

Other Insurance CoverageIf you have other insurance in addition to Molina Healthcare, you must tell your doctor or other provider. Your health care provider must bill your other insurance before billing Molina Healthcare. If your Molina Healthcare doctor does not accept your other insurance, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist can tell you how to match your HMO enrollment with your other insurance so you can use both insurance plans.

BadgerCare Plus and Medicaid SSIService & Copays Standard Plan SSI Benchmark Plan BadgerCare Plus Core PlanAny Pregnancy Related Visit

$0 $0 $0 Not Covered. Call us right away at 1- 888-999-2404 if you are pregnant and we

will help you change to another program that will cover pregnancy

BadgerCare Plus and Medicaid SSIService & Copays Standard Plan SSI Benchmark Plan BadgerCare Plus Core PlanInpatient Stays $0 $0 $50.00 per stay Not Covered

Day Treatment $0 $0 $10.00 $0

Narcotic Treatment $0 $0 $15.00 $0

Outpatient Services $0 $0 $15.00 $0


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When You May Be Billed for ServicesIt is very important to follow the rules when you get medical care so you are not billed for services. You must receive your care from Molina Healthcare providers and hospitals, unless you have our approval to go somewhere else. The only exception is for severe emergencies.

If you travel outside of Wisconsin and need emergency services, health care providers can treat you and send claims to Molina Healthcare. You may have co-payments for emergency services provided outside Wisconsin, but the charges for Medicaid covered services will be no more than charges for services in the network.

Molina Healthcare does not cover any service, including emergency services, provided outside the United States, Canada and Mexico. If you need emergency services while in Canada or Mexico, Molina Healthcare will cover the service only if the doctor or hospital’s bank is in the United States. Other services may be covered with HMO approval, if the provider has a United States bank. Please call Molina Healthcare if you receive any emergency services outside the United States.

If You Are Billed Under BadgerCare Plus-Standard Plan and Medicaid SSI, if you receive a bill for services, call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

You do not have to pay for covered services that are provided by a BadgerCare Plus or Medicaid SSI certified provider that Molina Healthcare is required to provide for you unless prior authorization is denied and you are told there will be a charge for the service before it is provided.

Generally, charging a member for a non-covered service is allowed, except for certain non-covered services or activities related to covered services, like missed appointments, telephone calls and translation services.

Under BadgerCare Plus-Benchmark Plan and Core Plan, Molina Healthcare and its providers and subcontractors may bill you for the deductibles or copays for covered services that are provided by a BadgerCare Plus certified provider.

You may request non-covered services from providers, and providers may collect payment for non-covered services from you if you accept responsibility for payment and make payment arrangements with the provider. Providers may bill you up to their usual and customary charges for non-covered services.

Copays For Molina BadgerCare Plus - Standard Plan members: Molina Healthcare and subcontractors may bill you for nominal copayments. The following members are exempt from copays:• Medicaid SSI members,• Nursing home residents,• Pregnant women,• Members under 19 years of age who are members of a federally recognized tribe, and• Members under 19 years of age with incomes at or below 100 percent of the Federal Poverty Level (FPL).

For Molina BadgerCare Plus - Benchmark and Core Plan Members: Molina Healthcare and its providers and subcontractors may bill you for copays for covered services or for other medical services that are provided by a BadgerCare Plus certified provider. The following Benchmark Plan members are exempt from copays: • Pregnant women, • Members 19 years of age and under who are members of a federally recognized tribe.


Services Covered By Molina HealthcareMolina Healthcare is responsible for providing all medically necessary covered services under BadgerCare Plus- Standard Plan, BadgerCare Plus-Benchmark Plan, BadgerCare Plus-Core Plan, and Medicaid SSI. Please review the chart below to learn more about your coverage. If you have questions about your coverage please call 1-888-999-2404 or 414-847-1776.

Service BadgerCare Plus Standard Plan

SSI BadgerCare Plus Benchmark Plan

BadgerCare PlusCore Plan

Chiropractic Services – is covered directly by the Wisconsin Medicaid Program not Molina Healthcare. You can receive these services from any chiropractor who will accept your ForwardHealth card.

$0.50 to $3 copayment per service.

$0 copayment $15.00 copayment $0.50 to $3 copayment per service.

Dental ServicesDental services only in Milwaukee, Ozaukee, Racine, Kenosha, Washington and Waukesha Counties

$0 copayment $0 copayment

Limited coverage of preventive, diagnostic, simple restorative, periodontics, and extractions for pregnant women and children.

Coverage limited to $750 per enrollment year.

A $200 deductible applies to all services except preventive and diagnostic.

Cost-sharing equal to 50% of allowable fee on all services.

Pregnant women are exempt from deductible and cost-sharing requirements for dental services

Coverage limited to emergency services only.

$0 copayment

Disposable Medical Supplies

Full coverage for covered items.

$0 copayment

Full coverage for covered items.

$0 copayment

Coverage of certain diabetic supplies, ostomy supplies and other disposable medical supplies (DMS) that are required with the use of a durable medical equipment (DME) item.

$0 copayment

Coverage of certain diabetic supplies, ostomy supplies and other disposable medical supplies (DMS) that are required with the use of a durable medical equipment (DME) item.

$0 copayment


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Drugs You may get drugs through any pharmacy that will take your ForwardHealth ID Card. Pharmacy services are provided directly through Wisconsin Medicaid and not Molina

Coverage of generic and brand name prescription drugs, and some over the counter (OTC) drugs.

Copayments:-$0.50 for OTC drugs-$1.00 for generic drugs-$3.00 for brand

Copayments are limited to $12.00 per member, per provider, per month. OTCs are excluded from this $12.00 maximum.

Coverage of generic and brand name prescription drugs, and some over the counter (OTC) drugs.

Copayments:-$0.50 for OTC drugs-$1.00 for generic drugs-$3.00 for brand

Copayments are limited to $12.00 per member, per provider, per month. OTCs are excluded from this $12.00 maximum.

Generic drug-only formulary with a few generic OTC drugs.

Members will be automatically enrolled in the Badger Rx Gold plan. This is a separate program administered by Navitus Health Solutions, which provides for a discount on the cost of drugs.

$5 copayment with no limits.

Generic-only formulary drug benefit with a limited number OTC drugs.

Some brand name drugs are covered. Refer to the ForwardHealth Portal for a list of drugs covered under the Core Plan.

Members will be automatically enrolled in the Badger Rx Gold plan. This is a separate program administered by Navitus Health Solutions, which provides for a discount on the cost of drugs

Up to $4 copayment for generic drugs and up to $8 for brand name drugs with a $24 copayment limit per month, per provider.

Durable Medical Equipment (DME)

$1 copayment $0 copayment Full coverage up to $2,500 per enrollment year.

$5 copayment per item.

Rental items are not subject to copayment but count toward the $2,500 annual limit.

Full coverage up to $2,500 per enrollment year.

$0 copayment

Health Screenings for Children

Full coverage of HealthCheck screenings and other services for individuals under age 21 years.

$0 copayment


$0 copayment


$0 copayment

Not applicable.

Hearing Services Full coverage.

$0 copayment

Full coverage.

$0 copayment

Limited coverage of services provided by an audiologist for members 18 years of age and older.

Hearing aids, hearing aid batteries, cochlear implants and bone-anchored hearing devices are not covered for members 18 years of age and older.

Full coverage for members 17 years of age and younger.

Hearing aids, hearing aid batteries, cochlear implants and bone-anchored hearing devices are covered for members 17 years of age and younger.

$15 per procedure, regardless of the number of procedures performed during one visit.

No coverage.


Home Care Services (Home Health, Private Duty Nursing and Personal Care)

Full coverage of private duty nursing, home health services, and personal care.

$0 copayment

Full coverage of private duty nursing, home health services, and personal care.

$0 copayment

Full coverage of home health services.

Coverage limited to 60 visits per enrollment year.

Private duty nursing and personal care are not covered.

$15 copayment per visit.

Coverage of home health services for 30 days following an inpatient stay. Discharge from the hospital must depend on having follow up home health care. Coverage is limited to 100 visits within the 30-day post hospitalization period

$0 copayment

Hospice Services $0 copayment $0 copayment Full coverage, up to 360 days per lifetime.

$0 copayment

$0 copayment

Inpatient Hospital Services

$0 copayment $0 copayment Full coverage, with the following dollar amount limits per enrollment year:•$6,300 for stays in a general acute care hospital for substance abuse.•$7,000 for stays in an Institute for Mental Disease (IMD) for substance abuse treatment.

Hospital stays for mental health and substance abuse services have a 30-day limit.

Copayments:•$100 per medical stay•$50 per stay for mental health and/or substance abuse treatment.

Full coverage (not including inpatient psychiatric stays in either an IMD or the psychiatric ward of an acute care hospital and inpatient substance abuse treatment).

$3 copayment per day for members with income up to 100% FPL with a $75 cap per stay.

$100 copayment per stay for members with income from 100% to 200% FPL.

There is a $300 total copayment cap per enrollment year for inpatient and outpatient hospital services for all income levels.


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Service BadgerCare Plus Standard Plan

SSI BadgerCare Plus Benchmark Plan

BadgerCare PlusCore Plan

Mental Health and Substance Abuse Treatment*

Full coverage (not including room and board).

$0 copayment

Full coverage (not including room and board).

$0 copayment

Coverage of this service is based on the Wisconsin State Employee Health Plan.

Covered services include outpatient mental health, outpatient substance abuse (including narcotic treatment), mental health day treatment for adults, substance abuse day treatment for adults and children, and child/adolescent mental health day treatment and inpatient hospital stays for mental health and substance abuse.

Services not covered are crisis intervention, community support program (CSP), Comprehensive Community Services (CCS), outpatient services in the home and community for adults, and substance abuse residential treatment.

$10 to $15 copayment per visit for all outpatient services: -$10 per day for all day treatment services.-$15 per visit for narcotic treatment services (no copayment for lab tests).-$15 per visit for outpatient mental health diagnostic interview exam, psychotherapy-individual or group (no copayment for electroconvulsive therapy and pharmacological management).-$15 per visit for outpatient substance abuse services.

Coverage limited to mental health therapy services provided by a psychiatrist only.


Nursing Home Services

$0 copayment $0 copayment Full coverage for stays at skilled nursing homes limited to 30 days per enrollment year.

$0 copayment

No coverage.

Outpatient Hospital - Emergency Room

$0 copayment $0 copayment $60 copayment per visit (waived if member admitted to hospital).

$3 copayment for members with income up to 100% FPL.

$60 copayment per visit for members with income from 100% to 200% FPL (waived if member admitted to hospital).

Outpatient Hospital Services

$0 copayment $0 copayment $15 copayment per visit

Full coverage up to 25 outpatient visits per enrollment year. Outpatient mental health and substance abuse treatment services are not covered

$3 copayment per visit for members with income up to 100% FPL.

$15 copayment per visit for members with income from 100% to 200% FPL.

$300 total copayment cap per enrollment year for inpatient and outpatient hospital services for all income levels.

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)

$1 copayment $0 copayment Coverage, limited to 20 visits per therapy discipline per enrollment year.

Also covers up to 36 visits per enrollment year for cardiac rehabilitation provided by a physical therapist. (The cardiac rehabilitation visits do not count towards the 20 PT visits.)

$15 copayment per visit, per provider.

There are no monthly or annual copayment limits.

Coverage limited to 20 visits per therapy discipline per enrollment year.

Cardiac rehabilitation visits are covered as part of PT and are subject to PT limitations

$0 copayment


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Physician Services

Full coverage, including laboratory and radiology.

$1 copayment limited to $30 per provider per calendar year.No copayment for emergency services, anesthesia or clozapine management.


$0 copayment

No copayment for emergency services, anesthesia or clozapine management.


$15 copayment per visit

No copayment for emergency services, preventive care, anesthesia or clozapine management.


Health education for members with asthma, diabetes or hypertension.

$0 copayment

No copayment for emergency services, anesthesia or clozapine management.

Podiatry Services $1 copayment limited to $30 per provider per calendar year.

$0 copayment $15 copayment $0 copayment

Prenatal /Maternity Care

Full coverage, including prenatal care coordination, preventive mental health, substance abuse screening and counseling for women at risk of mental health or substance abuse problems.

$0 copayment


$0 copayment


$0 copayment

Not Covered. Call us right away at 888-999-2404 if you are pregnant and we will help you change to another program that will cover pregnancy.

Reproductive Health Services

Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization.

$0 copayment for family planning services.





Family planning services provided by family planning clinics will be covered separately under the Family Planning Waiver program Only Services (FPOS).

Routine Vision Full coverage including coverage of eyeglasses.

$0 copayment

Full coverage including coverage of eyeglasses.

One eye exam every two years, with refraction.

$15 copayment per visit

No Coverage. General ophthalmological services are covered if billed with CPT codes 92002-92014 and certain qualifying diagnosis codes.

Smoking Cessation Services

Coverage includes prescription and OTC tobacco cessation products.

Refer to the drug benefit for information on copayments.

Coverage includes prescription and OTC tobacco cessation products.


Coverage includes prescription generic and OTC tobacco cessation products.


Coverage includes prescription generic and OTC tobacco cessation products.


Transportation – Ambulance, Specialized Medical Vehicle (SMV), Common Carrier

Full coverage of emergency transportation to and from a certified provider for a BadgerCare Plus covered service.

$0 copayment

Non-emergency transportation covered in Milwaukee County, Waukesha, Racine, Kenosha, Washington, and Sheboygan.

$0 copayment



$0 copayment



$0 copayment for SMV$50 copayment for Ambulance

Coverage limited to emergency transportation by ambulance.

Molina provides transportation for the annual comprehensive physical exam in Milwaukee County only. Once that exam is verified transportation to other BadgerCare Plus covered services is provided in Milwaukee County only.

$0 copayment


family Planning ServicesWe provide confidential family planning services to all members. This includes minors. If you do not want to talk to your Primary Care Provider (PCP) about family planning, call our Customer Service Department at 1-888-999-2404 or 414-847-1776. We will help you choose a Molina Healthcare family planning doctor who is different from your primary care doctor.

You can also go to any family planning clinic that will accept your ForwardHealth card even if the clinic is not part of Molina Healthcare; however, we encourage you to receive your family planning services from a Molina Healthcare doctor. That way we can better coordinate your health care.

Federal law allows members to choose their provider, including physicians and family planning clinics, for reproductive care and supplies.

HealthCheckHealthCheck is a preventive health checkup program for members under the age of 21 (not covered for BadgerCare Plus Core Plan members). The HealthCheck program covers complete health checkups. These checkups are very important for those under 21. Someone may look and feel well, yet may have a health problem. Your doctor wants to see those under 21 for regular checkups, not just when they are sick.

The HealthCheck program has three purposes: 1. To find and treat health problems early for those under 21. 2. To let you know about the special health services for those under 21. 3. To make those under 21 eligible for certain services not otherwise covered.

The HealthCheck program covers the medical care for any health problems found during the checkup including medical care, eye care and dental care.

The HealthCheck checkup includes:• Immunizations (shots) appropriate for age• Unclothed physical exam• Health and developmental history (including

anticipatory guidance)• Vision and hearing screening• Blood and urine lab tests (including blood lead

level testing when appropriate for age)• Dental screening and a referral to a dentist

beginning at age one.

Children age one and older will be referred to a dentist. You will receive help in choosing and getting to a dentist.

A referral by your doctor may make you eligible for some treatments not normally paid for by Wisconsin’s Medicaid program, as long as they are medically necessary.

Ask your child’s primary care doctor (PCP) when your child should have his/her next HealthCheck exam. Molina Healthcare will help arrange transportation for HealthCheck visits. Call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

BadgerCare Plus and Medicaid SSIService & Copays Standard

PlanSSI Benchmark Plan BadgerCare Plus Core Plan

HealthChecks $0 $0 $0 Not Covered

HealthCheck Scheduleage HealthCheck

examsBirth to one 6

Age one to two years 3

Age two to three years 2

Ages three to twenty-one years

1 per year


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dental ServicesMolina Healthcare provides covered dental services only in certain counties (Milwaukee, Kenosha, Racine, Waukesha, Washington and Ozaukee). If you live outside these areas your dental services are provided by the State not Molina for BadgerCare Plus members. Milwaukee, Kenosha, Racine and Waukesha counties for SSI members, BadgerCare Plus Core Plan has dental coverage limited to emergency services only. Please see the chart below to learn about what is covered under your Molina plan. The Benchmark Plan has limited dental benefits for certain populations. If dental is covered in your county, you must go to a Molina Healthcare dentist. See the Provider Directory or call DentaQuest at 1-888-307-6563 for the names of our dentists.

As a member of Molina Healthcare, you have a right to a routine dental appointment within 90 days after your formal request.

If Molina Healthcare does not cover dental services in your county, you may get dental services from any dentist who will accept your ForwardHealth card. Your dental services are provided by the State, not Molina Healthcare.

Standard Plan and SSI Members Preventive Dental Care

Molina Healthcare would like to remind you that oral health is vital to your total health. Molina has a group of dentists for you and your children to see. Please call us if you need help finding a dentist at 1-888-307-6563.

Call your dentist today for a dental exam. Routine exam appointments need to be made in advance.

Don’t delay, put a stop to decay, and make an appointment today!

Covered dental benefits include:• Dental cleanings and exams • Dental X-Rays• Sealants and fluoride treatments • Fillings and Crowns

It is important that you are on time for your dental appointments. If you need to change your time, try to let your dentist know at least 24 hours before your appointment. That way the dentist can schedule another patient in your time slot.

Remember your teeth are meant to last a lifetime, so take good care of them!

Dental Emergency

A dental emergency is an immediate dental service needed to treat dental pain, swelling, fever, infection, or injury to the teeth. Molina Healthcare covers emergency dental services for all members.

What To Do If You Or Your Child Has A Dental Emergency

If you already have a dentist who is with Molina Healthcare:• Call the dentist’s office.• Identify yourself or your child as having a dental emergency.• Tell the dentist’s office what the exact dental problem is, it may be something like a toothache or swollen

face. Make sure the office understands that you or your child is having a “dental emergency”.• Call us if you need help with transportation to your dental appointment.

If you do not currently have a dentist who is with Molina Healthcare:• Call 1-888-307-6563 to tell us that you/your child is having a dental emergency. We can help you get dental services.• Let us know if you need a ride to the dentist’s office.

You have a right to obtain treatment for your dental emergency within 24 hours after receipt of your request.


ambulanceMolina Healthcare will cover ambulance service for emergency care. We may also cover this service at other times, but you must have approval for all non-emergency ambulance trips. Call our 24-hour Nurse Advice Line - A new benefit to help you day and night. Please call our registered nurses 24 hours a day, 7days a week. Call 1-888-275-8750, Español 1-866-648-3537. For the hearing impaired, please call TTY/1-800-688-4889, Español TTY/1-866-833-4703.

Always call 911 in the case of a severe emergency!

Chiropractic ServicesSSI members in Milwaukee and Waukesha County can call Molina Health care at 888-999-2404 or 414-847-1776 to receive help in finding a chiropractor. All other members can receive services from any chiropractor who will receive you ForwardHealth ID card as this coverage is provide directly by the state.

TransportationFor transportation please call Customer Service at 1-999-888-2404. A Customer Service Representative will schedule a ride for you.

Molina Healthcare covers transportation by special medical vehicle (SMV) for those in wheelchairs. We may also cover this service for others if your doctor asks for it. Call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

After-hours transportation is reserved for emergencies only! If you need assistance, please call 1-888-999-2404 or 414-847-1776.

Core Plan - Non-emergency transportation is not covered. But Molina will pay for Core Plan members to get a ride to your comprehensive physical exam. Once you have had your exam, Molina will pay for transportation for all other BadgerCare Plus covered services in Milwaukee County only.

BadgerCare Plus and Medicaid SSIService & Copays Standard Plan SSI Benchmark Plan BadgerCare Plus Core PlanAmbulance $0 $0 $50.00 per ride $0

BadgerCare Plus and Medicaid SSIService & Copays Standard Plan SSI Benchmark Plan BadgerCare Plus Core Plan

Chiropractic Services – is covered directly by the Wisconsin Medic-aid Program not Molina Health-care. You can receive these services from any chiropractor who will accept your ForwardHealth card.

$0.50 to $3 copayment per

service

$0 $15.00 Full coverage as of July 1, 2009. $0.50 to $3 copayment

per service.


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Pharmacy BenefitsYour prescriptions and certain over the counter items are provided by the State, not Molina Healthcare.

You may receive a prescription from a Molina doctor, specialist, or dentist. You can fill your prescription at any pharmacy that is a provider for BadgerCare Plus and Medicaid SSI.

Please show your ForwardHealth ID card to the pharmacy when you get your prescriptions filled. You may have co-pays or have limits on covered medications.

Care evaluation (SSI members only)As a member of Molina, you will be asked to speak with a trained staff member about your health care needs. Your care coordinator will contact you within the first 60 days of being enrolled with Molina to schedule a time to talk about your medical history and the care you need. It is very important that you talk with your care coordinator. If you have questions or you would like to contact Molina directly to schedule a care evaluation session, please call 1-888-999-2404.

Comprehensive Physical exam (Core Plan members only)As a member of the Core Plan, it is your responsibility to schedule and receive a physical exam with your doctor within the first year of being enrolled in the Core Plan. This is very important because if you do not get a physical exam, you will lose your health care benefits. You will receive notification from Molina about scheduling this exam. If you need help to schedule your physical exam, please call 1-888-999-2404 or 414-831-3380.

If you are unable to schedule and receive a physical exam through Molina, please call Enrollment Services at 1-800-291-2002.

Molina will pay for Core Plan members to get a ride to your comprehensive exam. Once you have had your exam, Molina will pay for transportation for all other BadgerCare Plus covered services in Milwaukee County only.


Molina Healthcare Has a Quality Improvement Program If you want a copy of Molina Healthcare’s Quality Improvement Program description or progress report, please call Customer Service at 1-888-999-2404.

If You MoveIf you are planning to move, contact your county Department of Social or Human Services. If you move to a different county, you must also contact the Department of Social or Human Services in your new county to update your eligibility.

• If you move out of Molina Healthcare’s service area, call the HMO Enrollment Specialist at 1-800-291-2002.

Molina Healthcare will only provide emergency care if you move out of our service area. The Enrollment Specialist will help you choose an HMO that serves your area.

HMO exemptionsAn HMO exemption means you are not required to join an HMO to receive your health care benefits. Most exemptions are granted for only a short period of time so you can complete a course of treatment before you are enrolled in an HMO.

If you think you need an exemption from HMO enrollment, call the HMO Enrollment Specialist at 1-800-291-2002 for more information.

Living Will or Power of attorney for Health CareYou have the right to make decisions about your medical care. You have the right to accept or refuse medical or surgical treatment. You also have the right to plan and direct the types of health care you may receive in the future if you become unable to express your wishes. You can let your doctor know about your wants or wishes by completing a living will or power of attorney for health care form.

You have a right to file a grievance with the Department of Health Services, Division of Quality Assurance if your advance directive, living will or power of attorney wishes are not followed. You may request help in filing a grievance.

Contact your doctor for more information on living wills or power of attorney for health care.


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right to Medical recordsYou have the right to ask for copies of your medical records from your provider(s). Please call 1-888-999-2404 for help. You may have to pay a fee to copy your medical records. You may also correct questionable information in your medical records if your doctor agrees to the correction.

Second Medical OpinionsA second medical opinion on recommended treatments may be appropriate in some cases. Contact your doctor, or our Customer Service Department at 1-888-999-2404 or 414-847-1776.

Molina Healthcare’s Member advocatesMolina Healthcare has Member Advocates to help you get the care you need. The Advocates can answer your questions about getting health care from Molina Healthcare. The Advocates can also help you solve any problems you may have getting health care from Molina Healthcare.

You can reach Molina’s Member Advocates at 1-888-999-2404.

external advocateIf you have problems getting services while you are enrolled with Molina Healthcare for Medicaid SSI services, call the SSI HMO Advocate at 1-800-708-3034.

State of Wisconsin Managed Care Ombuds ProgramThe State has Managed Care Ombuds who can help you with any questions or problems you have as a HMO member. The Managed Care Ombuds can tell you how to get the care you need from your HMO. The Managed Care Ombuds can also help you solve problems or complaints you may have about the HMO Program or your HMO. Call 1-800-760-0001 and ask to speak to a Managed Care Ombuds.

Physician Incentive PlanYou are entitled to ask if we have special financial arrangements with our physicians that can affect the use of referrals and other services you might need. To get this information, please call our Customer Service Department at 1-888-999-2404 or 414-847-1776 and request information about our physician payment arrangements.

Provider CredentialsYou have the right to information about our providers that includes the provider’s education, board certification and recertification. To get this information, call our Customer Service Department at 1-888-999-2404 or 414-847-1776.


Member rights• You have the right to ask for an interpreter and have one provided to you during any BadgerCare Plus and/or

Medicaid SSI covered service.• You have the right to receive the information provided in this member handbook in another language or

another format.• You have the right to receive health care services as provided for in Federal and State law.• All covered services must be available and accessible to you. When medically appropriate, services must be

available 24 hours a day, seven (7) days a week.• You have the right to be treated with dignity and respect.• You have the right to make decisions about your health care.• You have the right to receive information about treatment options including the right to request a second

opinion. • You have the right to be free from any form of restraint or seclusion used as a means of force, control, ease or

reprisal.

Complaints, Grievances and appealsWe would like to know if you have a complaint about your care at Molina Healthcare. Please call Molina Healthcare’s Member Advocates at 1-888-999-2404 or 414-847-1776 if you have a complaint or you can write to us at: Molina Healthcare Attn: Grievance/Complaint Department 2400 S. 102nd Street West Allis, WI 53227

If you want to talk to someone outside of Molina Healthcare about the problem, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist may be able to help you solve the problem, or can help you write a formal grievance to Molina Healthcare or to the BadgerCare Plus and Medicaid SSI programs.

You may also file a complaint with the Wisconsin BadgerCare Plus and Medicaid SSI Program. Please call Molina’s Member Advocate if you need help to write a formal grievance to Molina Healthcare or to the BadgerCare Plus and Medicaid SSI programs.

The address to complain to the Wisconsin BadgerCare Plus and Medicaid SSI Programs is: BadgerCare Plus and Medicaid SSI Managed Care Ombuds P.O. Box 6470 Madison, WI 53716-0470 1-800-760-0001

If your complaint or grievance needs action right away because a delay in treatment would greatly increase the risk to your health, please call Molina as soon as possible at 1-888-999-2404 or 414-847-1776.

We cannot treat you differently than other members because you file a complaint. Your health care benefits will not be affected.


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fair HearingsYou have the right to appeal to the State of Wisconsin Division of Hearings and Appeals (DHA) for a Fair Hearing if you believe your benefits are wrongly denied, limited, reduced, delayed or stopped by Molina Healthcare. An appeal must be made no later than 45 days after the date of the action being appealed. If you appeal this action to DHA before the effective date, the service may continue. You may need to pay for the cost of services if the hearing decision is not in your favor.

If you want a Fair Hearing, send a written request to: Department of Administration Division of Hearings and Appeals P.O. Box 7875 Madison, WI 53707-7875

The hearing will be held in the county where you live. You have the right to bring a friend or be represented at the hearing. If you need a special arrangement for a disability, or for English language translation, please call 608-266-3096 (voice) or 608-264-9853 (hearing impaired).

We cannot treat you differently than other members because you request a Fair Hearing. Your health care benefits will not be affected.

If you need help writing a request for a Fair Hearing, please call either the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001 or HMO Enrollment Specialist at 1-800-291-2002.

How Can I Stop Health Care fraud?Health care fraud takes money from health care programs and leaves less money for real medical care. Here are some ways you can help stop fraud:• Do not give your ForwardHealth ID Card number to anyone other than a health care provider, a clinic, or

hospital, and only when receiving care.• Never let anyone borrow your ForwardHealth Card.• Never sign a blank insurance form.• Be careful about giving out your Social Security number.• Check your mail for medical bills for services that you did not receive.

If you think fraud has taken place, please report it right away. You do not have to fear revenge. Your report will be kept private.

You can report fraud, without giving us your name, by sending a letter to:Attn: Director of Compliance(CONFIDENTIAL)Molina Healthcare2400 S 102ndWest Allis, WI 53227

To report waste, abuse and fraud, gather as much information as possible.

When reporting a provider (e.g. doctor, dentist, counselor, etc.) provide the following:• Name, address, and phone number of provider;• Name and address of the facility (hospital, nursing home and home health agency, etc.)• Medicaid number of the provider and facility is helpful;• Type of provider (physician, physical therapist, and pharmacist, etc.);


• Names and number of other witnesses who can aide in the investigation;• Dates of event; and• Summary of what happened

You can report fraud, waste and abuse by calling toll free at 1-877-477-5643. You can remain anonymous.

When reporting a client (a person who receives benefits), provide the following:• The person’s name;• The person’s date of birth, social security number, or case number if available;• The city where the person resides; and• Specific details about the waste, abuse or fraud.

Or you can contact Wisconsin’s Medicaid Fraud Unit at:Medicaid Fraud and Abuse UnitContact: Medicaid Fraud Control UnitDepartment of Justice17 W. Main St., P.O. Box 7857Madison, WI 53707Telephone: 608-266-9222

Your Civil rightsMolina Healthcare provides covered services to all eligible members regardless of:• Age• Race• Religion• Color• Disability• Sex• Physical condition• Sexual orientation• National origin• Marital status• Arrest or conviction record• Military participation


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nOTICe Of PrIvaCY PraCTICeS MOLIna HeaLTHCare Of WISCOnSIn, InC.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Molina Healthcare of Wisconsin, Inc . (“Molina Healthcare” or “we”) uses and shares protected health information about you to provide your health benefits. We use and share your information to carry out treatment, payment, and health care operations. We also use and share your information for other reasons as allowed and required by law. We have the duty to keep your health information private. We have policies in place to obey the law. The effective date of this notice is June 15, 2011.

PHI stands for protected health information. PHI means health information such as medical records that include your name, member number or other identifiers, and is used or shared by Molina Healthcare.

Why does Molina Healthcare use or share your PHI? We use or share your PHI to provide you with health care benefits. Your PHI is used or shared for treatment, payment and health care operations.

For Treatment Molina Healthcare may use or share your PHI to give you, or arrange for, your medical care. This treatment also includes referrals between your doctors and other health care providers. For example, Molina Healthcare may share information about your health condition with a specialist. This helps the specialist talk about your treatment with your doctor.

For Payment Molina Healthcare may use or share PHI to make decisions on payment. This may include claims, approvals for treatment and decisions about medical needs. Your name, your condition, your treatment, and supplies given may be written on the bill. For example, we may let a provider know that you have our benefits. We would also tell the provider the amount of the bill that we would pay.

For Health Care Operations Molina Healthcare may use or share PHI about you to run our health plan. For example, we may use information from your claim to let you know about a health program that could help you. We may also use or share your PHI to solve member concerns. Your PHI may also be used to see that claims are paid right.

Health care operations involve many daily business needs. They include, but not limited, to the following:• Improving quality • Actions in health programs to help members with certain conditions (such as asthma)• Conducting or arranging for medical review• Legal services, including fraud and abuse programs• Actions to help us obey laws• Addressing member needs, including solving complaints and grievances.

We will share your PHI with other companies (“business associates”) that perform different kinds of activities for our health plan.

We may also use your PHI to give you reminders about your appointments. We may use your PHI to give you information about other treatment, or other health-related benefits and services.


When can Molina Healthcare use or share your PHI without getting written authorization (approval) from you? In addition to treatment, payment and health care operations, the law allows or requires Molina to use and share your PHI for several other purposes including the following:

Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if: • The information is directly relevant to the family or friend’s involvement with your care or payment for that

care; and • You have either orally agreed to the disclosure or have been given an opportunity to object and have not

objected.

Required by law Molina Healthcare will use or share information about you as required by law. We will share your PHI when required by the Secretary of the Department of Health and Human Services (HHS).

Public Health Your PHI may be used or shared for public health activities. This may include helping public health agencies to prevent or control disease.

Health Care Oversight Your PHI may be used or shared with government agencies. They may need your PHI for audits.

Research Your PHI may be used or shared for research in certain cases, when approved by a privacy or institutional review board.

Legal or Administrative Proceedings Your PHI may be used or shared for legal proceedings, such as in response to a court order.

Law Enforcement Your PHI may be used or shared with police to help find a suspect, witness or missing person.

Health and Safety PHI may be shared to prevent a serious threat to public health or safety.

Government Functions Your PHI may be shared with the government for special functions, such as national security activities.

Victims of Abuse, Neglect or Domestic Violence Your PHI may be shared with legal authorities, if we believe that a person is a victim of abuse or neglect.

Workers Compensation Your PHI may be used or shared to obey Workers Compensation laws.

Other Disclosures PHI may be shared with funeral directors or coroners to help them do their jobs.

When does Molina Healthcare need your written authorization (approval) to use or share your PHI? Molina Healthcare needs your written approval to use or share your PHI for a purpose other than those listed in this notice. You may cancel a written approval that you have given to Molina Healthcare. Your cancellation will not apply to actions already taken by us because of the approval you already gave to us.


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What are your health information rights?

You have the right to:

•RequestRestrictionsonPHIUsesorDisclosures(SharingofYourPHI) You may ask Molina Healthcare not to share your PHI to carry out treatment, payment or health care operations. You may also ask us to not share your PHI with family, friends or other persons you name who are involved in your health care. However, Molina Healthcare is not required to agree to your request. You will need to fill out a form to make your request.

•RequestConfidentialCommunicationsofPHI You may ask Molina Healthcare to give you your PHI in a certain way or at a certain place to help keep your PHI private. We will follow reasonable requests, if you tell us how sharing all or a part of that PHI could put your life at risk. You will need to fill out a form to make your request.

•ReviewandCopyYourPHI You have a right to review and get a copy of your PHI held by us. This may include records used in making coverage, claims and other decisions as a Molina Healthcare member. You will need to fill out a form to make your request. We may charge you a reasonable fee for copying and mailing the records. In certain cases we may deny the request. Important Note: We do not have complete copies of your medical records. Please contact your PCP to get a copy of your medical chart.

•AmendYourPHI You may ask that we amend (change) your PHI. This involves only those records kept by Molina Healthcare about you as a member. You will need to fill out a form to make your request. You may file a letter disagreeing with us if we deny the request.

•ReceiveanAccountingofPHIDisclosures(SharingofyourPHI) You may ask that Molina Healthcare give you a list of certain parties that we shared your PHI with during the six years prior to the date of your request. The list will not include PHI shared as follows: • for treatment, payment or health care operations• to persons about their own PHI• sharing done with your authorization • incident to a use or disclosure otherwise permitted or required under applicable law; • as part of a limited data set for research or public health activities; • PHI released in the interest of national security or for intelligence purposes; • to correctional institutions having custody of an inmate; or• shared prior to April 14, 2003

You must fill out a form to request a list of PHI disclosures. We may charge a reasonable fee if you ask for this list more than once in a 12-month period.

You may make any of the requests listed above. Please call Molina Healthcare Member Services at 1-888-999-2404.


What can you do if your rights have not been protected? You may complain to Molina Healthcare and to the Department of Health and Human Services, if you believe your privacy rights have been violated. We will not do anything against you for filing a complaint. Your care will not change in any way.

You may complain to us at: Molina Healthcare of Wisconsin, Inc.Attention: Director of Member Services2400 S. 102nd StreetWest Allis, WI 53227Phone: 1-888-999-2404

You may file a complaint with the Secretary of the U.S. Department of Health and Human Services at: Office for Civil RightsU.S. Department of Health and Human Services233 N. Michigan Ave., Suite 240Chicago, IL 60601Voice Phone (312) 886-2359; TDD (312) 353-5693

What are the duties of Molina Healthcare? Molina Healthcare is required to:• Keep your PHI private• Give you written information such as this on our duties and privacy practices about your PHI• Follow the terms of this Notice

This Notice is Subject to Change Molina Healthcare reserves the right to change its information practices and terms of this notice at any time. If we do, the new terms and practices will then apply to all PHI we keep. If we make any material changes, a new notice will be sent to you by US Mail.

Contact Information If you have any questions, please contact the following office:Molina Healthcare of Wisconsin, Inc.Attention: Director of Member Services2400 S. 102nd StreetWest Allis, WI 53227Phone: 1-888-999-2404


Provider directory

Specialty Care Providers

Primary C

are Providersu

rgent Care

d

ental Clinics

Hospitals

Hospitals

Brown County

Aurora Baycare Medical Center 2845 Greenbrier Rd Green Bay, WI 54311-6519 (920) 288-8000

Bellin Memorial Hospital 744 S Webster Ave Green Bay, WI 54301-3505 (920) 433-3500

St. Vincent Hospital 835 S Van Buren St Green Bay, WI 54301-3526 (920) 433-8115

Chippewa County

Ministry Our Lady of Victory Hospital 1120 Pine St Stanley, WI 54768-0220 (715) 644-5571

Dane County

Meriter Hospital 202 S Park St Madison, WI 53715-1507 (608) 267-6000

University of Wisconsin Hospital 600 Highland Ave Madison, WI 53792-0001 (608) 662-0817

Dodge County

Watertown Regional Medical Center 125 Hospital Dr Watertown, WI 53098-3303 (920) 261-4210

Door County

Ministry Door County Medical Center 323 S 18th Ave Sturgeon Bay, WI 54235-1401 (920) 743-5566

Jefferson County

Fort Memorial Hospital 611 Sherman Ave E Fort Atkinson, WI 53538-1960 (920) 568-5000

Kenosha County

Aurora Medical Center Kenosha 10400 75th St Kenosha, WI 53142-7884 (262) 697-7000

Kenosha Medical Center 6308 8th Ave Kenosha, WI 53143-5031 (262) 656-2011

St. Catherine’s Medical Center 9555 76th St Pleasant Prairie, WI 53158-1984 (262) 656-2800

Langlade County

Langlade Hospital 112 E 5th Ave Antigo, WI 54409-2710 (715) 623-2331

Lincoln County

Good Samaritan Health Center 601 S Center Ave Merrill, WI 54452-3404 (715) 536-5511

Ministry Sacred Heart Hospital 401 W Mohawk Dr Tomahawk, WI 54487-2274 (715) 453-7700

Manitowoc County

Aurora Medical Center Manitowoc 5000 Memorial Dr Two Rivers, WI 54241-3900 (920) 794-5000

Marathon County

Aspirus Wausau Hospital 333 Pine Ridge Blvd Wausau, WI 54401-4120 (715) 847-2385

Ministry St. Clare’s Hospital 3400 Ministry Pkwy Weston, WI 54476-5220 (715) 393-3000

Marinette County

Bay Area Medical Center 3100 Shore Dr Marinette, WI 54143-4242 (715) 735-4203

Milwaukee County

Aurora Sinai Medical Center 945 N 12th St Milwaukee, WI 53233-1305 (414) 219-2000

Aurora St. Luke’s Medical Aurora West Allis Medical Center 8901 W Lincoln Ave West Allis, WI 53227-2409 (414) 647-3147

Children’s Hospital of Wisconsin 9000 W Wisconsin Ave Milwaukee, WI 53226-4874 (414) 266-2000

Columbia St. Mary’s Hospital Milwaukee 2323 N Lake Dr Milwaukee, WI 53211-4508 (414) 291-1000

Midwest Orthopedic Specialty Hospital 10101 S 27th St, 2nd Floor Franklin, WI 53132-7209 (414) 817-5800

Orthopaedic Hospital of Wisconsin 575 W River Woods Pkwy Glendale, WI 53212-1058 (414) 961-6800

Sacred Heart Rehabilitation Institute 2025 E Newport Ave Milwaukee, WI 53211-2906 (414) 298-6700

The Wisconsin Heart Hospital 10000 W Bluemound Rd Wauwatosa, WI 53226-4321 (414) 778-7800

Wheaton Franciscan Healthcare Franklin 10101 S 27th St Franklin, WI 53132-7209 (414) 325-4700

Wheaton Franciscan Healthcare St. Francis Hospital 3237 S 16th St Milwaukee, WI 53215-4526 (414) 647-5000

Wheaton Franciscan Healthcare St. Joseph’s Hospital 5000 W Chambers St Milwaukee, WI 53210-1650 (414) 447-2000

Oconto County

Community Memorial Hospital 855 S Main St Oconto Falls, WI 54154-1241 (920) 846-3444

Oconto Hospital and Medical Center 820 Arbutus Ave Oconto, WI 54153-2004 (920) 835-1100

Oneida County

Howard Young Medical Center 240 Maple St Woodruff, WI 54568-9190 (715) 356-8000

Ministry Saint Mary’s Hospital 2251 N Shore Dr Rhinelander, WI 54501-6710 (715) 361-2000

Ozaukee County

Aurora Medical Center Grafton 975 N Prt Washington Rd Grafton, WI 53024-9201 (920) 288-5042

Columbia Center 13125 N Prt Washington Rd Mequon, WI 53097-2416 (262) 243-7408

Columbia St. Mary’s Hospital Ozaukee 13111 N Prt Washington Rd Mequon, WI 53097-2416 (262) 243-7300

Portage County

Ministry Saint Michael’s Hospital 900 Illinois Ave Stevens Point, WI 54481-3114 (715) 346-5000

Racine County

Aurora Memorial Hospital of Burlington 252 McHenry St Burlington, WI 53105-1828 (262) 767-6000

Lakeview Specialty Hospital and Rehab 1701 Sharp Rd Waterford, WI 53185-5214 (262) 534-7297

Wheaton Franciscan Healthcare All Saints Medical Center 1320 Wisconsin Ave Racine, WI 53403-1978 (262) 687-4011

Shawano County

Shawano Medical Center 309 N Bartlette St Shawano, WI 54166-2127 (715) 526-2111

Sheboygan County

Aurora Sheboygan Memorial Medical Center 2629 N 7th St Sheboygan, WI 53083-4932 (920) 451-5000

Taylor County

Memorial Health Center 135 S Gibson St Medford, WI 54451-1622 (715) 748-8100

Vilas County

Eagle River Memorial Hospital 201 Hospital Rd Eagle River, WI 54521-8835 (715) 479-7411

Walworth County

Aurora Lakeland Medical Center W3985 County Rd NN Elkhorn, WI 53121-4337 (262) 741-2000

Washington County

Aurora Medical Center Hartford 1032 E Sumner St Hartford, WI 53027-1608 (262) 673-2300

Waukesha County

Aurora Medical Center Summit 36500 Aurora Dr Summit, WI 53066-4899 (262) 434-1000

Oconomowoc Memorial Hospital 791 Summit Ave Oconomowoc, WI 53066-3844 (262) 569-9400

Waukesha Memorial Hospital 725 American Ave Waukesha, WI 53188-5031 (262) 928-1000

Wheaton Franciscan Healthcare Elmbrook Memorial 19333 W North Ave Brookfield, WI 53045-4132 (262) 785-2000

Waupaca County

New London Family Medical Center 1405 Mill St New London, WI 54961-2155 (920) 531-2000

Riverside Medical Center 800 Riverside Dr Waupaca, WI 54981-1943 (715) 258-1000

Waushara County

Wild Rose Community Memorial Hospital 601 Grove Ave Wild Rose, WI 54984-6903 (920) 622-3257

Winnebago County

Aurora Medical Center Oshkosh 855 N Westhaven Dr Oshkosh, WI 54904-7668 (920) 456-6000

Children’s Hospital of Wisconsin 130 2nd St Neenah, WI 54956-2883 (920) 969-7900

Theda Clark Medical Center 130 2nd St Neenah, WI 54956-2883 (920) 729-3100

Wood County

Ministry Saint Joseph’s Hospital 611 St Joseph Ave Marshfield, WI 54449-1832 (715) 387-1713

Riverview Hospital 410 Dewey St Wisconsin Rapids, WI 54494-4715 (715) 423-6060

Brown County Wood County


urgent Care

Brown CountyAurora BayCare Health Center 2253 W Mason St Green Bay, WI 54303-4706 (920) 327-7300 Mon - Fri 8am - 8pm; Sat & Sun 8am - 4pm

Aurora BayCare Medical Center 2845 Greenbrier Rd Green Bay, WI 54311-6519 (920) 288-4060 Emergency 24 Hours 7 Days/ Urgent Care Mon - Fri 8am-8pm Sat, Sun 9am-5pm Closed Holidays

Aurora Health Center 1881 Chicago St De Pere, WI 54115-3770 (920) 403-8000 Mon - Fri 8am - 8pm; Sat & Sun 9am - 5pm Closed Christmas Day and New Years Day

Dodge County

Watertown Regional Medical Center - UW Health Partners 125 Hospital Dr Watertown, WI 53098-3303 (920) 262-4222 24 Hours 7 Days A Week in Emergency Department

Door County

Aurora Health Center 1910 Alabama St Sturgeon Bay, WI 54235-3532 (920) 746-7200 Mon - Fri 8am - 8pm; Sat & Sun 8am - 4pm; Closed Christmas Day and New Years Day

Green Lake County

CHN Walk-In Care (in Berlin Memorial Hospital 225 Memorial Dr Berlin, WI 54923-1243 (920) 361-5535 Mon - Fri 11am - 7pm; Sat, Sun and Holidays 10am - 6pm

Jefferson County

Fort Healthcare Lake Mills Urgent Care 200 E Tyranena Park Rd Lake Mills, WI 53551-9678 (920) 648-3113 Mon - Fri 5pm - 10pm; Sat 8am - 8pm; Sun Noon-10pm

Fort Memorial Hospital Urgent Care 611 Sherman Ave E Fort Atkinson, WI 53538-1960 (920) 568-5330 Mon - Fri 5pm - 11pm; Sat & Sun Noon-11pm

Kenosha County

St Catherines Medical - United Hospital System 9555 76th St Pleasant Prairie, WI 53158-1984 (262) 577-8600 24 Hours 7 Days Includes all major Holidays

Lincoln County

Good Samaritan Health Urgent Care 601 S Center Ave Merrill, WI 54452-3404 (715) 536-5511 Mon - Fri 8am - 8:30pm; Sat, Sun and Holidays 8am - 6:30pm

Manitowoc County

Aurora Manitowoc Clinic South 4100 Dewey St Manitowoc, WI 54220-5497 (920) 686-5700 Mon - Fri 7am - 7pm; Sat 8am - 5pm; Sun 8am -3pm

Aurora Two Rivers Clinic 2219 Garfield St Two Rivers, WI 54241-2416 (920) 793-6350 Mon - Fri 8am - 5pm; Sat 8am - 12pm

Milwaukee County

Aurora Advanced Healthcare Walk In 3003 W Good Hope Rd Milwaukee, WI 53209-2042 (414) 352-7951 Mon-Fri 8am-7pm; Sat-Sun 9am-5pm; Closed Christmas and New Years

Aurora Advanced Healthcare-Walk In 3289 N Mayfair Rd Wauwatosa, WI 53222-3203 (414) 771-8602 Mon-Sun 8am-9pm; Holidays 9am-5pm; Closed Christmas; Open New Years 9am-5pm

Aurora Medical Center 6901 W Edgerton Ave Greenfield, WI 53220-4420 (414) 325-5244 Mon - Fri 8am - 9pm; Sat & Sun 9am - 9pm; Holidays 9am-2pm; Call first for hours on Christmas and New Years Day

Aurora Medical Group Inc 9200 W Loomis Rd, Ste 212 Franklin, WI 53132-9621 (414) 529-9200 Mon-Fri 7am-8pm; Sat & Sun 8am-4pm; All Holidays 10am-3pm

Aurora Urgent Care 946 N Van Buren St Milwaukee, WI 53202-3216 (414) 276-4242 Mon - Fri 7am - 8pm; Sat & Sun 8am - 4pm; Closed Holidays

Childrens Urgent Care - Children’s Hospital (2nd Floor of Clinic Building 9000 W Wisconsin Ave, Ste 260 Milwaukee, WI 53226-4874 (414) 266-2280 Mon - Fri 5pm - 10pm; Sat & Sun 11am - 5pm; Call for Holiday Hours

Childrens Urgent Care 16th 1032 S Cesar E Chavez Dr, Lower Level Milwaukee, WI 53204-2203 (414) 385-0646 Mon - Fri 5pm - 10pm; Sat & Sun 11am - 5pm; Closed all major Holidays

Columbia St Marys Cathedral Square 734 N Jackson St Milwaukee, WI 53202-4602 (414) 277-6500 Mon-Fri 8am-9pm; Sat & Sun 8am-4pm; Holidays 8am - 4pm; No Infants under 6 months old

CSM River Woods Outpatient Center 375 W River Woods Pkwy Glendale, WI 53212-1080 (414) 963-7015 Mon -Fri 8am - 7pm; Sat - Sun 8am - 6pm; Call for Holiday hours

Kids Urgent Care 1308 S 16th St Milwaukee, WI 53204-2711 (414) 831-0100 Mon-Fri 9am-5p

Documents

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