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iCare Medicaid SSI and BadgerCare Plus Member Rights

We want you to understand your rights as a member.  iCare's Member Advocates can help you get the care and help you need.  If you have a problem or a complaint, your Member Advocate can help you get answers. They can also help you with appeals, should you wish to appeal a decision about your health coverage.

iCare is here for you!

Member Advocate Complaints and Grievances Appeals  

 

Your Member Rights

  • You have the right to have an interpreter with you during any covered service
  • You have the right to get the info in the member handbook in another language or format.
  • You have the right to get 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 days a week
  • You have the right to get information about treatment options including the right to request a second opinion.
  • You have the right to make decisions about your health care.
  • You have the right to be treated with dignity and respect.
  • You have the right to be free from any form of restraint or seclusion used as a means of force, control, ease, or reprisal.
  • You have the right to be free to exercise your rights without adverse treatment by the HMO and its network providers.
  • You may switch HMOs without cause during the first 90 days of iCare enrollment.
  • You have the right to switch HMOs, without cause, if the State imposes sanctions or temporary management on iCare.
  • You have the right to receive info from iCare regarding any significant changes with iCare at least 30 days before the effective date of the change

 

Your Civil Rights

iCare provides covered services to all eligible members regardless of the following:

  • Age
  • Color
  • Disability
  • National Origin
  • Race
  • Gender Identity
  • Sex

All medically necessary covered services are available and will be provided in the same manner to all members. All persons or organizations connected with iCare that refer or recommend members for services shall do so in the same manner for all members.

 

Your Right to Privacy

iCare is firmly committed to protecting your personal and health related information. Review our privacy statement for more detail.

Your Right for Information...

 
About Physician Incentive Plan

You have the right 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 info, call our Customer Service Department at 1-800-777-4376 and request information about our physician payment arrangements.

 
About Provider Credentials

You have the right to info about our providers including the provider’s education, board certification, and recertification. To get this information, call our Customer Service Department at 1-800-777-4376.

 
About Clinical Practice Guidelines

iCare has implemented our Clinical Practice Guidelines with the support of network physicians on our review committee. Each clinical practice guideline represents an accepted standard of care in the medical profession that may be used for diagnosing, managing or treating conditions like asthma, COPD, diabetes, hypertension, obesity and drug and alcohol treatment. None of the information within these guidelines is intended to interfere with decisions made by your treating physician about your care.

For a hard copy of our Clinical Practice Guidelines, contact your Care Coordinator or for a general overview of our policy, please click here.

 
About Completing an Advance Directive, Living Will, Or Power Of Attorney For Health Care

You have the right to make decisions about your medical care. You have the right to accept or refuse medical or surgical treatment. You have the right to plan and direct the types of health care you may get in the future if you become unable to express your wishes. You can let your doctor know about your wishes by completing an advance directive, living will, or power of attorney for health care. Contact your doctor for more information.

You have the right to file a grievance with the DHS 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.

Division of Quality Assurance
PO Box 2969
Madison, WI 53701-2969
Phone: 608-266-8481
Fax: 608-267-0352

About Your Medical Records

You have the right to ask for copies of your medical records from your provider(s). We can help you get copies of these records. Please call 1-800-777-4376 for help. Please note that you may have to pay to copy your medical records. You may correct inaccurate information in your medical records if your doctor agrees to the correction.

 

About When You May be Billed for Services

It is very important to follow the rules when you access medical care so you are not billed for services. You must get your care from iCare network doctors, clinics, and hospitals unless you have our approval. 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 iCare. 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. You will have to pay for any service you get outside Wisconsin if the health care provider refuses to submit claims or refuses to accept iCare payment as payment in full.

 

About Covered and Non-Covered Services

You do not have to pay for covered services other than required copayments. The amount of your co-pay cannot be greater than it would have been in fee-for-service. To help ensure that you are not billed for services, you must see a provider in iCare’s network. The only exception is for emergencies. If you are willing to accept financial responsibility and make a written payment plan with your provider, you may ask for noncovered services. Providers may bill you up to their usual and customary charges for noncovered services. If you get a bill for a service you did not agree to, or believe that you should not have been billed, please call 1-800-777-4376.

 

About Co-Payments

iCare and its providers and subcontractors may bill you for small service and/or prescription drug fees, called co-payments. The following members do not have to pay co-payments:

  • iCare Medicaid SSI members
  • Nursing home residents
  • Pregnant women
  • Members under 19 years of age who are members of a federally recognized tribe
  • Members under 19 years of age with incomes at or below 100 percent of the Federal Poverty Level (FPL)
  • iCare Family Care Partnership members

With your plan, you do not have to pay for covered services other than required copayments. The amount of your co-pay cannot be greater than it would have been in fee-for-service. To help ensure that you are not billed for services, you must see a provider in iCare’s network. The only exception is for emergencies. If you are willing to accept financial responsibility and make a written payment plan with your provider, you may ask for noncovered services. Providers may bill you up to their usual and customary charges for noncovered services. If you get a bill for a service you did not agree to, or believe that you should not have been billed, please call 1-800-777-4376.

 
About Medical Services Received Outside of Wisconsin

If you travel outside Wisconsin and need emergency care, health care providers in the area where you travel can treat you and send the bill to iCare. You may have copayments for emergency services provided outside Wisconsin.

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

If you get a bill for services, call our Customer Service Department at 1-800-777-4376 right away.

 

If You Have Other Insurance

If you have other insurance in addition to iCare, you must tell your doctor or other provider. Your health care provider must bill your other insurance before billing iCare. If your iCare network 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.

Medicaid SSI & BadgerCare Plus Member Advocacy

iCare’s Member Advocate

iCare has a Member Advocate (Member Rights Specialist) to help you get the care you need. The Advocate can answer your questions about getting health care from iCare. The Advocate can also help you solve any problems you may have getting health care from iCare. You can reach the Advocate at 1-800-777-4376 or 414-231-1076.

 

State of Wisconsin Ombuds Program

The state has designated Ombuds (individuals who provide neutral, confidential and informal assistance) who can help you with any questions or problems you have as an HMO member. The Ombuds can tell you how to get the care you need from iCare. The Ombuds can help you solve problems or complaints you may have about iCare. Call 1-800-760-0001 to ask to talk to an Ombuds.

 

What is a Complaint or Grievance?

A grievance is any expression of dissatisfaction by a member or member’s authorized representative about:

  1. Independent Care Health Plan's services or procedures
  2. A contracted provider’s services or procedures
  3. Services arranged by iCare or a contracted provider
  • iCare will treat every complaint as a grievance. This means that iCare will keep track of member complaints, take your concerns seriously and make sincere efforts to resolve them.
  • Dissatisfaction with a determination of coverage is not considered a grievance, but may be treated as an appeal.  It is iCare’s responsibility to determine whether your complaint is a grievance or an appeal, or has pieces of both.
COMPLAINTS/GRIEVANCES

If you have a complaint about your care, please contact iCare at:

 

Member Advocate

Independent Health Care Plan

1555 N. RiverCenter Dr., Suite 206

Milwaukee, WI 53212

Tel: 1-800-777-4376

TTY: 1-800-947-3539

Fax: 1-414-231-1092

APPEALS

If you are asking to appeal a decision for your Medicaid SSI or BadgerCare Plus benefits:

A written request must be postmarked within 45 calendar days from the date of the denial letter. 

You have three options for an appeal. You may choose:

  1. A Local Appeal or
  2. DHS Review and/or
  3. Fair Hearing

You may begin with any of these three options. But you cannot request a local appeal after completing a DHS Review or Fair Hearing.

To learn more about each of these three options:  

Click Here

Your HMO Managed Care Ombudsman can also help

If you want to talk to someone outside of iCare about the problem, call the HMO Managed Care Ombudsman at 1-800-760-0001. The Ombudsman may be able to help you solve the problem, or can help you write a formal complaint to iCare or to the BadgerCare Plus/Medicaid SSI program.

The address to file a complaint with the Medicaid SSI program is:

 

Medicaid SSI Managed Care Ombuds

P.O. Box 6470

Madison, WI  53716-0470

Phone: 1-800-760-0001

The address to file a complaint with the BadgerCare Plus program is:

 

BadgerCare Plus Managed Care Ombuds

P. O. Box 6470

Madison, WI  53716-0470

Phone: 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 iCare as soon as possible at 1-800-777-4376.

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

​​​​​​H2237_IC200   DHS approved 08/13/19
Last Updated 08/13/19

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