Molina Member Handbook

Welcome to the Molina family.

Member Handbook and Provider DirectoryWisconsin | 2012 | Version 2

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.

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www.MolinaHealthcare.com

The Molina Healthcare StoryDelivering Access to Quality Care Across Three Decadesthrough government-funded At Molina Healthcare, we programs such as Medicaid, have been helping mothers, children, families and seniors the Childrens Health Insurance Program (CHIP) gain access to quality care for over three decades. We help and Medicare. Molina Healthcare also offers health patients navigate the healthcare information management system and build community partnerships to develop and business process outsourcing solutions for solutions to the challenges our C. David Molina, M.D., MPH members face. Molinas history state Medicaid programs through its subsidiary, Molina and member-focused approach began with the vision of Dr. C. David Molina, an Medicaid Solutions. emergency room doctor who saw people in need. Dr. Molina wanted to help, so he Molina provides NCQA-accredited opened a community clinic where caring care and services that focus on for people was more important than their promoting health, wellness and ability to pay. improved patient outcomes. While Molina Healthcare continues to grow, we always put people first. Today, Molina Healthcare serves the diverse needs of 1.6 million plan members We treat everyone like family, just as Dr. Molina did. and beneficiaries across the United States

Facts about Molina Healthcare All of Molina Healthcares eligible health plans are accredited by the National Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving healthcare quality. Molinas 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 Americas 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 Molinas Community Champions Awards recognize and affirm the contributions of everyday community heroes.2Effective 02-2012


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

Section 1- Member HandbookInTrOduCTIOn Important Telephone Numbers....................................................................................................................................................5 Selecting a Primary Provider (PCP) ............................................................................................................................................6 ForwardHealth Card .....................................................................................................................................................................6 24 Hour Nurse Advice ..................................................................................................................................................................6 GeTTInG Care Primary Care Provider (PCP) ......................................................................................................................................................7 Making an Appointment With Your Doctor ...............................................................................................................................7 Changing Your Doctor ..................................................................................................................................................................7 Missed Appointments ...................................................................................................................................................................7 All Doctor Visits ............................................................................................................................................................................8 Emergency Care ............................................................................................................................................................................8 Emergency Care from A Non-Molina Healthcare Provider .......................................................................................................8 How to Get Medical Care When You Are Away From Home .....................................................................................................9 Urgent Care ...................................................................................................................................................................................9 Mental Health and Substance Abuse Services.......................................................................... ................................................10 Pregnant Women and Deliveries ................................................................................................................................................10 Other Insurance Coverage ..........................................................................................................................................................10 When You May Be Billed For Services .......................................................................................................................................11 BenefITS Services Covered By Molina Healthcare ....................................................................................................... 12, 13, 14, 15, 16,17 Family Planning Services ............................................................................................................................................................18 HealthCheck ................................................................................................................................................................................18 Dental Services ............................................................................................................................................................................19 Ambulance ..................................................................................................................................................................................20 Chiropractic Services ..................................................................................................................................................................20 Transportation ............................................................................................................................................................................20 Pharmacy Benefits.......................................................................................................................................................................21 Care Evaluation ...........................................................................................................................................................................21 Comprehensive Physical Exam...................................................................................................................................................21 ServICeS Quality Improvement Program..................................................................................................................................................22 If You Move .................................................................................................................................................................................22 HMO Exemptions .......................................................................................................................................................................22 Living Will or Power of Attorney for Health Care ....................................................................................................................22 Right to Medical Records............................................................................................................................................................23 Second Medical Opinions...........................................................................................................................................................23 Molina Healthcares Member Advocate .....................................................................................................................................23 External Advocate .......................................................................................................................................................................23 State Of Wisconsin HMO OMBUDS Program .........................................................................................................................23 Physician Incentive Plan .............................................................................................................................................................23 Provider Credentials ...................................................................................................................................................................23 Member Rights ............................................................................................................................................................................24 Complaints, Grievances and Appeals .........................................................................................................................................24 Fair Hearings ...............................................................................................................................................................................25 How Can I Stop Health Care Fraud?..........................................................................................................................................25 Your Civil Rights .........................................................................................................................................................................26 Privacy Notice ........................................................................................................................................................... 27, 28, 29, 30

Section 2 - Provider directory

Hospitals .......................................................................................................................................................................................31 Urgent Care ............................................................................................................................................................................ 32-33 Dental Clinics ......................................................................................................................................................................... 34-36 Primary Care Providers ......................................................................................................................................................... 37-87 Specialty Care Providers ...................................................................................................................................................... 88-204

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

Nurse Advice LineWe 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 providers 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, Espaol 1-866-648-3537. For the hearing impaired, please call TTY / 1-800-688-4889, Espaol TTY / 1-866-833-4703.

Mental Health, Substance Abuse Services1-877-491-0322 Beacon Health Strategies

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

Vision Care414-760-7400 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 CareFor transportation, please call Customer Service at 1-999-888-2404. A Customer Service Representative will schedule a ride for you.

Member Advocate1-888-999-2404 414-847-1776

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

Enrollment Specialist1-800-291-2002

BadgerCare Plus or Medicaid SSI Pharmacy Member Services1-800-362-3002

Molina Care Management Department1-888-999-2404 414-847-1776

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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 Every person must have this mailing. choose your PCP from those available in will not FORM that is included ina PCP. You canMail it in the envelope provided. Youthe Provider Directory section of this stamp. need a book. A PCP can be a doctor or a nurse practitioner.

Selecting a Primary Care Provider (PCP)

After you have selected a doctor that you and your children would like Racine County NOTE: Racine County members should not use this form. If you are ato have as your Primary Care Provider, fill out the PRIMARY CARE PROVIDER (PCP) SELECTION FORM that is included in this mailing. Mail it in member, please call (262) 687-2606 to select your PCP.If you need help choosing a doctor please call our Customer Service Department at NOTE: Racine County members (414) 847-1776 or 1- 888-999-2404. who are assigned to or chose All Saints need to call 1-262-687-2778 to select Please note the following important items:

the envelope provided. You will not need a stamp.

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

Please notehealth appointment as soon as possible. routine the following important items: Dont your to schedule a HealthCheck with your child or childrens PCP. ContactforgetPCP for all medical care. you the emergency room patient true your selected If Use are not an established only for withemergencies. doctor, it is best to make a routine health appointment soon your Forward as Carry as possible. or Forward Health ID card with you at all times. Show your card Do not forget to schedule a HealthCheck with your child or childrens PCP. whenever you receive medical care. There are two different plans. Use the emergency room only for true emergencies.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 you and show it every time you get care. You may have problems Always carry your ForwardHealth card with any other health insurance cards you may have. Remember to always giveif you do notproviders your Forward Health or Forward Also, bring any other health getting care or prescriptions health care have your ForwardHealth card with you. ID card.

forwardHealth Id Card

Forward Health or Forward ID Card

insurance cards you may have. Remember to always give health care providers your ForwardHealth card.

24 Hour nurse advice LineMolina Healthcares 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 providers normal business hours. When your child is sick and you arent 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 5 languages. You can call Molinas 24- Hour Nurse Line at 1-888-275-8750, Espaol 1-866-648-3537. For the hearing impaired, please call TTY/ 1-800-688-4889, Espaol 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 womens 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 doctorIf 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 doctors office and let them know as soon as possible. Otherwise, the provider may refuse to schedule future appointments.

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all doctor visitsService & Copays Office Visit PCP Office Visit Specialist Nurse Practitioner Services Chiropractic Services is covered directly by the Wisconsin Medicaid Program $0.50 to $3 not Molina Healthcare. You can copayment per receive these services from any service. chiropractor who will accept your ForwardHealth card. Podiatry Services $1 Immunizations $0 HealthChecks up to age 21 $0 Any Pregnancy Related Visit $0 $0 $0 BadgerCare Plus and Medicaid SSI Standard Plan SSI Benchmark Plan BadgerCare Plus Core Plan $1 $0 $15.00 $0 $1 $0 $15.00 $0 $1 $0 $15.00 $0

$0

$15.00

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

$0 $0 $0

$15.00 $0 $0

$0 $0 Does not apply to Core Plan members 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 Trouble breathing Serious broken bones Unconsciousness Severe or unusual bleeding Suspected poisoning Suspected heart attack Suspected stroke Severe pain Severe burns Prolonged or repeated seizures 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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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 doctors 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 Bruises or sprains Minor burns Non-severe bleeding Minor cuts 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 providers 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, Espaol 1-866-648-3537. For the hearing impaired, please call TTY/ 1-800-688-4889, Espaol 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.

BadgerCare Plus and Medicaid SSIService & Copays Emergency Room Services Standard Plan $0 SSI $0 Benchmark Plan $60.00 per visit only if not admitted to the hospital BadgerCare Plus Core Plan No copayment per visit for members with income up to 100% FPL. $60.00 copayment per visit for members with income from 100% to 200% FPL (only if not admitted to the hospital) $0

Urgent Care Services

$0

$0

$15.00

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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. BadgerCare Plus and Medicaid SSI Benchmark Plan BadgerCare Plus Core Plan $50.00 per stay Not Covered $10.00 $0 $15.00 $0 $15.00 $0

Service & Copays Inpatient Stays Day Treatment Narcotic Treatment Outpatient Services

Standard Plan $0 $0 $0 $0

SSI $0 $0 $0 $0

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 its 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. Service & Copays Any Pregnancy Related Visit Standard Plan $0 BadgerCare Plus and Medicaid SSI SSI Benchmark Plan BadgerCare Plus Core Plan Not Covered. Call us right away at $0 $0 1- 888-999-2404 if you are pregnant and we will help you change to another program that will cover 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.


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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 hospitals 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 BilledUnder 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.

CopaysFor 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.

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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 Chiropractic Services is

BadgerCare Plus Standard Plan$0.50 to $3 copayment per service.

SSI$0 copayment

BadgerCare Plus Benchmark Plan$15.00 copayment

BadgerCare Plus Core Plan$0.50 to $3 copayment per service.

covered directly by the Wisconsin Medicaid Program not Molina Healthcare. You can receive these services from any chiropractor who will accept your ForwardHealth card. Limited coverage of Coverage limited to preventive, diagnostic, simple emergency services only. restorative, periodontics, and extractions for pregnant $0 copayment 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 costsharing requirements for dental services

Dental Services

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

$0 copayment

$0 copayment

Full coverage for covered Disposable Medical Supplies 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 $1 copayment Equipment (DME)

$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

Full coverage of HealthCheck screenings and other services for individuals under age 21 years. $0 copayment Full coverage. $0 copayment

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

Not applicable.

Hearing Services Full coverage.$0 copayment

No coverage.

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

Full coverage of private Full coverage of private duty nursing, home health duty nursing, home health services, and personal services, and personal care. care. $0 copayment $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

$0 copayment Inpatient Hospital Services

$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 30day 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 PlanFull coverage (not including room and board). $0 copayment

SSI

BadgerCare Plus Benchmark PlanCoverage 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, psychotherapyindividual or group (no copayment for electroconvulsive therapy and pharmacological management). -$15 per visit for outpatient substance abuse services.

BadgerCare Plus Core PlanCoverage limited to mental health therapy services provided by a psychiatrist only.

Mental Health and Substance Abuse Treatment*

Full coverage (not including room and board). $0 copayment

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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.

Full coverage, including laboratory and radiology. $0 copayment No copayment for emergency services, anesthesia or clozapine management.

Full coverage, including laboratory and radiology. $15 copayment per visit No copayment for emergency services, preventive care, anesthesia or clozapine management. $15 copayment 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 Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization. $0 copayment for family planning services. One eye exam every two years, with refraction. $15 copayment per visit

Full coverage, including laboratory and radiology. Health education for members with asthma, diabetes or hypertension. $0 copayment No copayment for emergency services, anesthesia or clozapine management. $0 copayment Not Covered. Call us right away at 888-9992404 if you are pregnant and we will help you change to another program that will cover pregnancy.

Podiatry Services $1 copayment limited Prenatal / Maternity Care

to $30 per provider per calendar year. 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 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

Reproductive Health Services

Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization. $0 copayment for family planning services.

Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization. $0 copayment for family planning services. Full coverage including coverage of eyeglasses.

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

No Coverage. General ophthalmological services are covered if billed with CPT codes 92002-92014 and certain qualifying diagnosis codes. Coverage includes prescription generic and OTC tobacco cessation products.

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. Refer to the drug benefit for information on copayments. Full coverage of emergency transportation to and from a certified provider for a BadgerCare Plus covered service. Non-emergency transportation covered in Milwaukee County, Waukesha, Racine, Kenosha, Washington, and Sheboygan. $0 copayment

Coverage includes prescription generic and OTC tobacco cessation products.

Refer to the drug Refer to the drug benefit benefit for information for information on on copayments. copayments. Full coverage of emergency transportation to and from a certified provider for a BadgerCare Plus covered service. Coverage limited to emergency transportation by ambulance.

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

Molina provides transportation for the annual comprehensive physical exam in Milwaukee County only. Non-emergency transportation covered Once that exam is verified in Milwaukee County, transportation to other Waukesha, Racine, BadgerCare Plus covered Kenosha, Washington, services is provided in and Sheboygan. Milwaukee County only. $0 copayment for SMV $0 copayment $50 copayment for Ambulance

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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. HealthCheck Schedule The HealthCheck checkup includes: age HealthCheck Immunizations (shots) appropriate for age exams Unclothed physical exam Health and developmental history (including Birth to one 6 anticipatory guidance) Age one to two years 3 Vision and hearing screening Age two to three years 2 Blood and urine lab tests (including blood lead Ages three to twenty-one 1 per year level testing when appropriate for age) years 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 Wisconsins Medicaid program, as long as they are medically necessary. Ask your childs 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. Service & Copays HealthCheckswww.MolinaHealthcare.com

Standard Plan $0

SSI $0

BadgerCare Plus and Medicaid SSI Benchmark Plan BadgerCare Plus Core Plan $018

Not CoveredEffective 02-2012

Member Handbook

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 CareMolina 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. Dont delay, put a stop to decay, and make an appointment today!Covered dental benefits include:

Dental cleanings and exams Sealants and fluoride treatments

Dental X-Rays 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 EmergencyA 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 EmergencyIf you already have a dentist who is with Molina Healthcare: Call the dentists office. Identify yourself or your child as having a dental emergency. Tell the dentists 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 dentists office. You have a right to obtain treatment for your dental emergency within 24 hours after receipt of your request.

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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, Espaol 1-866-648-3537. For the hearing impaired, please call TTY/1-800-688-4889, Espaol TTY/1-866-833-4703. Always call 911 in the case of a severe emergency! Service & Copays Ambulance Standard Plan $0 SSI $0 BadgerCare Plus and Medicaid SSI Benchmark Plan BadgerCare Plus Core Plan $50.00 per ride $0

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. Service & Copays 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. Standard Plan $0.50 to $3 copayment per service BadgerCare Plus and Medicaid SSI SSI Benchmark Plan BadgerCare Plus Core Plan $0 $15.00 Full coverage as of July 1, 2009. $0.50 to $3 copayment per service.

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.


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Member Handbook

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.

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Molina Healthcare Has a Quality Improvement ProgramIf you want a copy of Molina Healthcares 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 Healthcares 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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Member Handbook

right to Medical recordsYou have the right to ask for copies of your medical records from your provider(s). Please call 1-888-9992404 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 Healthcares 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 Molinas 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 providers education, board certification and recertification. To get this information, call our Customer Service Department at 1-888-999-2404 or 414-847-1776.

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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 Healthcares 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 Molinas 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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Effective 02-2012

Member Handbook

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 Healthcare P.O. Box 270208, West 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.);Effective 02-2012

25


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 persons name; The persons 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. You can report fraud, without giving us your name, by sending a letter to: Attn: Director of Compliance (CONFIDENTIAL) Molina Healthcare P.O. Box 270208, West Allis, WI 53227 Or you can contact Wisconsins Medicaid Fraud Unit at: Medicaid Fraud and Abuse Unit Contact: Medicaid Fraud Control Unit Department of Justice 17 W. Main St., P.O. Box 7857 Madison, WI 53707 Telephone: 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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Effective 02-2012

Member Handbook

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.

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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 friends 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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Effective 02-2012

Member Handbook

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.

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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 Services 2400 S. 102nd Street West Allis, WI 53227 Phone: 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 Rights U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Voice 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 Services 2400 S. 102nd Street West Allis, WI 53227 Phone: 1-888-999-2404


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Effective 02-2012

Brown County

HospitalsLanglade CountyLanglade Hospital 112 E 5th Ave Antigo, WI 54409-2710 (715) 623-2331 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. Josephs Hospital 5000 W Chambers St Milwaukee, WI 53210-1650 (414) 447-2000

Wood County

Provider directory

Brown CountyAurora 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

Portage CountyMinistry Saint Michaels Hospital 900 Illinois Ave Stevens Point, WI 54481-3114 (715) 346-5000

Waukesha CountyAurora 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

Lincoln CountyGood 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

Racine CountyAurora 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

Hospitals

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

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

Dane CountyMeriter 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

Waupaca CountyNew 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

urgent Care

Marathon CountyAspirus Wausau Hospital 333 Pine Ridge Blvd Wausau, WI 54401-4120 (715) 847-2385 Ministry St. Clares Hospital 3400 Ministry Pkwy Weston, WI 54476-5220 (715) 393-3000

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

Oconto CountyCommunity 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

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

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

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

dental Clinics

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

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

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

Oneida CountyHoward Young Medical Center 240 Maple St Woodruff, WI 54568-9190 (715) 356-8000 Ministry Saint Marys Hospital 2251 N Shore Dr Rhinelander, WI 54501-6710 (715) 361-2000

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

Milwaukee CountyAurora Sinai Medical Center 945 N 12th St Milwaukee, WI 53233-1305 (414) 219-2000 Aurora St. Lukes Medical Aurora West Allis Medical Center 8901 W Lincoln Ave West Allis, WI 53227-2409 (414) 647-3147 Childrens Hospital of Wisconsin 9000 W Wisconsin Ave Milwaukee, WI 53226-4874 (414) 266-2000 Columbia St. Marys 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

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

Primary Care Providers Specialty Care Providers

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

Ozaukee CountyAurora 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. Marys Hospital Ozaukee 13111 N Prt Washington Rd Mequon, WI 53097-2416 (262) 243-7300

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

Kenosha CountyAurora 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. Catherines Medical Center 9555 76th St Pleasant Prairie, WI 531581984 (262) 656-2800Effective 02-2012

Wood CountyMinistry Saint Josephs Hospital 611 St Joseph Ave Marshfield, WI 54449-1832 (715) 387-1713 Riverview Hospital 410 Dewey St Wisconsin Rapids, WI 544944715 (715) 423-6060

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

31


Brown County

urgent CareKenosha CountySt Catherines Medical United Hospital System 9555 76th St Pleasant Prairie, WI 531581984 (262) 577-8600 24 Hours 7 Days Includes all major Holidays Childrens Urgent Care Childrens 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-5pm; Sat by Appointment only Closed Thanksgiving, Christmas and New Years Kids Urgent Care 8532 W Capitol Dr Milwaukee, WI 53222-1848 (414) 463-6640 Mon-Fri 6pm-9pm; Sat 1pm-7:30pm; Sun 2pm-7:30pm; Call for Holiday hours (Age21/under) Lake Shore Medical Clinic Walk In Only 331 E Puetz Rd Oak Creek, WI 53154-3254 (414) 570-4330 Mon - Fri 12pm - 8pm; Sat & Sun 10am - 4pm; Call For Holiday Hours Medpoint Family Care Center 2501 W Silver Spring Dr, Ste 3 Glendale, WI 53209-4217 (414) 461-9250 Mon - Fri 9:00am - 5pm; Closed Sat, Sun and all major Holidays Milwaukee Community Medical Center 5310 W Capitol Dr Milwaukee, WI 53216-2263 (414) 431-5004 Mon - Thur 9am - 6pm; Fri 2pm-7pm; Sat 10am-3pm Closed, Sun and Holidays Milwaukee Health Services 2555 N Martin Luther King Dr Milwaukee, WI 53212-2709 (414) 372-8080 Mon - Fri 5pm - 10pm; Sat 11pm - 5pm; Closed Sun and all major Holidays Milwaukee Health Services Isaac Coggs Heritage Health Center 8200 W Silver Spring Dr Milwaukee, WI 53218-2552 (414) 760-3900 Mon 8am - 7:30pm; Tues - Fri 8am - 5:30pm; Limited Staff -Closed Sat, Sun and all major Holidays Milwaukee Immediate Care 1971 W Capitol Dr Milwaukee, WI 53206-1909 (414) 873-9800 Mon & Wed 10am-8pm; Tues,Thurs,Fri 10am-2pm; Sat 10am-1pm; Sun 11am-2pm; Closed all major Holidays Oak Creek Urgent Care 8201 S Howell Ave, Ste 400 Oak Creek, WI 53154-8336 (414) 570-1122 Mon - Fri 10am - 8pm; Sat 10am - 4pm; Sun 10am-2pm; Closed all major Holidays St Francis Urgent Care 3237 S 16th St Milwaukee, WI 53215-4526 (414) 647-5165 Mon - Sun 7am - 3am; Open all major Holidays WFHC - Franklin Urgent Care 10101 S 27th St Franklin, WI 53132-7209 (414) 325-8460 Mon - Fri 7am - 3am; Sun & Sat 7am - 3am; Open all major Holidays WFHC St Josephs Urgent Care 201 N Mayfair Rd Wauwatosa, WI 53226-4216 (414) 259-7235 24 Hours 7 Days Includes all major Holidays Wheaton Franciscan Urgent Care 9252 N Green Bay Rd Brown Deer, WI 53209-1104 (414) 527-7565 Mon - Fri 8am - 8pm; Sat & Sun 8am - 4pm; Closed Holidays

Racine County

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 8am8pm 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

Outagamie CountyThedaCare FastCare Darboy W3208 Van Roy Rd Appleton, WI 54915-4086 (866) 455-8111 Mon - Fri 8:30am - 8:30pm; Sat 8:30am - 5pm; Sun 10am - 5pm ThedaCare FastCare Northland 1000 W Northland Ave Appleton, WI 54914-1496 (866) 455-8111 Mon - Fri 8:30am - 8:30pm; Sat 8:30am - 5pm; Sun 10am - 5pm

Lincoln CountyGood 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

Ozaukee CountyAurora Advanced Healthcare Urgent Care 215 W Washington St Grafton, WI 53024-1700 (262) 375-3707 Mon - Fri 8am - 7pm; Sat & Sun and all major Holidays 9am - 5pm; Closed Christmas Columbia St Marys Urgent Care- Cedar Mills N143W6515 Pioneer Rd Cedarburg, WI 53012-2705 (262) 377-6933 Mon - Fri 8:30am - 5pm; Sat 8am - 11:30pm Closed Sun and Holidays

Manitowoc CountyAurora 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

Dodge CountyWatertown 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 CountyAurora 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

Milwaukee CountyAurora 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 HealthcareWalk 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

Portage CountySt Michaels Hospital Urgent Care 900 Illinois Ave Stevens Point, WI 54481-3114 (715) 343-3100 7:30am - 10pm 7 Days a week

Green Lake CountyCHN 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

Racine CountyAll Saints Walk In Care 3807 Spring St Racine, WI 53405-1667 (262) 687-8150 Mon - Fri 8am - 8pm; Sat 8am - 4pm; Sun 10am - 4pm Closed all major Holidays Aurora Health Center 8348 Washington Ave Racine, WI 53406-3733 (262) 884-4088 Mon - Fri 7am - 10pm; Sat & Sun 8am - 4pm; Call for Holiday hours Aurora Health Center 818 Forest Ln Waterford, WI 53185-4585 (262) 514-3700 Mon - Fri 7am - 8pm; Sat & Sun 8am - 4pm; Closed Thankgiving, Christmas and New Years Day

Jefferson CountyFort 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

Oconto CountyOconto Hosp & Med Center Urgent Care 820 Arbutus Ave Oconto, WI 54153-2004 (920) 835

Documents

Molina Member Handbook