Medicaid SSI

MEMBER
HANDBOOK

Friends for Health. www.icare-wi.org

Friends for Life.
 TABLE OF CONTENTS
Interpreter Services, Important Phone Numbers........................................................2
Welcome to iCare, The iCare Difference........................................................................2
Benefits of iCare Medicaid SSI.......................................................................................2
Your ForwardHealth Card,Primary Care Physician (PCP).............................................3
Referrals and Prior Approvals, Emergency Care..........................................................3
What to Expect When You Access Emergency Services...............................................4
Urgent Care, After Hours Service..................................................................................4
Getting Care When You Are Away from Home.............................................................5
Pregnant Women & Deliveries, When You May be Billed for Services.......................5
Billing Members..............................................................................................................5
Other Insurance.................................................................................................................................6
Services Covered by iCare..............................................................................................................6
MENTAL HEALTH & SUBSTANCE ABUSE.................................................................................6
FAMILY PLANNING....................................................................................................................6
MAMMOGRAMS........................................................................................................................6
DENTAL SERVICES..................................................................................................................... 6
CHIROPRACTIC...........................................................................................................................7
FLU SHOTS............................................................................................................................7
HEALTH CHECK............................................................................................................................7
TRANSPORTATION.....................................................................................................................8
AMBULANCE...............................................................................................................................8
PHARMACY BENEFITS...............................................................................................................8
CARE COORDINATION...............................................................................................8
HEALTH EDUCATION................................................................................................. 8
If You Move.......................................................................................................................8
Second Medical Opinion................................................................................................ 8
HMO Exemptions,Living Will or Power of Attorney, Right to Medical Records........ 9
iCares Member Advocate, External Advocate.............................................................9
State of WI HMO Ombuds Program, Complaints, Grievances & Appeals...................9
Physician Incentive Plan, Provider Credentials...........................................................10
Clinical Practice Guidelines...........................................................................................10
iCares Quality Improvement Program........................................................................10
Customer Service, Member Rights, Your Civil Rights.................................................11
Notice of Privacy Practices............................................................................................11

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My Health Care Contacts...............................................................................................14
Interpreter Services
English For help to translate or
understand this, please call 1-800-777-4376
(TTY 1-800-947-3529).
Spanish Si necesita ayuda para traducir o
entender este texto, por favor llame al
telfono 1-800-777-4376
(TTY 1-800-947-3529).
Russian care from iCare doctors, clinics and hospitals.
, See the iCare Medicaid SSI Provider
1-800-777-4376 (TTY 1-800-947-3529).
Hmong Yog xav tau kev pab txhais cov
ntaub ntawv no kom koj totaub, hu rau
1-800-777-4376 (TTY 1-800-947-3529).
Interpreter services are provided free of
charge to you. Alternative formats are
available for the visually impaired.
Important iCare
Telephone Numbers
Customer Service 1-800-777-4376
Call 24 hours-a-day, 7 days-a-week
TDD/TTY 1-800-947-3529
Nurse Advice Line 1-800-679-9874
Call 24 hours-a-day, 7 days-a-week
Welcome to iCare
Welcome to Independent Care Health Plan
(iCare)! We are glad you decided to get your
health care needs met through us. Our plan
offers the same benefits as Medicaid fee-for-
service, or Title 19, but adds more services.
Independent Care Health Plan is a complete
health care plan with strong ties to
community and social services programs for
people with physical, developmental or
emotional disabilities. With iCare Medicaid
SSI, Care Coordinators help you with
medical, dental, behavioral health and vision
through a process called care coordination.
Care coordination takes into account that
both medical and social needs must be met
in order to improve your quality of life.
Within 60 days of enrollment we will
complete an assessment with you to help
understand your health needs and goals.
We will develop a plan of care based on the
assessment, which we will share with you
and your Primary Care Provider (PCP). As a
member of iCare, you will get all your health
Directory for a list of these providers. You
may also call our Customer Service
Department at 1-800-777-4376. Providers
not taking new patients are marked in the
Provider Directory.
iCare members also have access to the Nurse
Advice Line. The Nurse Advice Line offers a
24-hour, 7 days-a-week resource for
healthcare advice and information. Reliable
health information is provided by Registered
Nurses by calling 1-800-679-9874.
The iCare Difference
Independent Care Health Plan for Medicaid
SSI brings together your medical, social and
community services needs. We work with
iCare Medicaid SSI Benefits
n Coordination of medical, community
and social services needs
n Personal Care Coordinator
n 24-hour Nurse Advice Line
doctors, nurses and other health care
providers who:
n Support people with different abilities
n Are close to your home
n Are sensitive to the needs of many
cultures
As a Medicaid member, you can get help
with transportation to Medicaid covered
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 medical appointments. We can help you
choose a PCP to bring together all your
medical care. We also can help you find
support groups, provide resources for you to
locate affordable housing, food and clothing,
and suggest opportunities for you to
interact with others. iCare
Medicaid SSI members
are assigned a care
coordinator who will
help you access all your
health needs.
Your ForwardHealth Card
Your ForwardHealth card is how your doctor
will know you are a Medicaid SSI member.
Always carry your ForwardHealth card with
you, show it every time you get care, and tell
your doctor that you belong to iCare. You
may have problems getting care or
prescriptions if you do not have your card
with you. Also, bring any other health
insurance cards you may have.
In addition, please have your ForwardHealth
card and your ID number available when
you call Customer Service. We need this in
order to look up your benefit information.
Primary Care Physician-PCP
You are required to have a Primary Care
Physician (PCP) assigned to you. It is
important to call your PCP first when you
need care. This doctor 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 and give you a referral.
Some specialty services require a referral,
some do not. Your doctor knows when a
referral is needed.
You can choose your PCP from those
available in the iCare Medicaid SSI Provider
Directory. NOTE: For women, you may also
see a womens health specialist (for example,
an OB/GYN doctor or a nurse midwife)
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without a referral, in addition to choosing
your PCP. There are HMO doctors who are
sensitive to the needs of many cultures. We
can assist you to find one (you can change
your PCP up to two times a year, more often
with good cause.) A specialist can serve as
PCP, if necessary.
To choose a PCP, or to change to a different
PCP, call your care coordinator or our
Customer Service Department at 1-800-777-
4376.
Referrals and Prior Approvals
The following services need a referral from
your PCP:
n Oral Surgery
n Plastic Surgery
Prior approvals are needed for certain
surgeries and other types of care. Your PCP
will know when you need a referral and/or
prior approval. If you do not receive a
referral for the above services, talk to your
PCP or call Customer Service at 1-800-777-
4376.
Emergency Care
Emergency care is care needed right away.
This may be caused by an injury or a sudden
illness. Some examples are:
n Choking
n Severe or unusual bleeding
n Trouble breathing
n Suspected poisoning
n Serious broken bones
n Suspected heart attack
n Unconsciousness
n Suspected stroke
n Severe burns
n Convulsions
n Severe pain
n Prolonged or repeated seizures
If you need emergency care, go to an iCare
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.
If you must go to a non-iCare hospital or
provider, call iCare at 1-800-777-4376 as
soon as you can and tell us what happened.
This is important, so we can help you get
follow-up care.
Remember, hospital emergency rooms are
for true emergencies only. Call your doctor
or our 24-hour emergency number at 1-800-
777-4376 before you go to the emergency
room, unless your emergency is severe.
What to Expect When You
Access Emergency Services
When you get to the hospital, a nurse may
ask about your symptoms, take your blood
pressure, temperature and pulse, ask when
you last ate or drank, and ask you about
your medical history.
You may not feel like answering questions,
but the information will help provide you
with the best possible emergency care.
Patients with the most serious needs are
treated first in the emergency room.
After you are treated, you may be: asked to
contact your physician, admitted to the
hospital or discharged with written
instructions. If you are prescribed
medications, make sure you ask the nurse or
doctor:
What the medication is
When to take the medication
How much medication to take
How long to take the medication
About possible side effects and what to do
if you notice them
Do not be afraid to ask questions if you do
not understand something. Its important
that you know how to take care of yourself
when you return home. If you have a friend
or relative with you, make sure they hear the
health care providers instructions as well.
Post-stabilization services are medically
necessary non-emergency services given to
you after you have been stabilized following
an emergency medical condition. Post-
stabilization care services are a covered
benefit, but they may require authorization.
For more information about accessing these
services, you can call iCare 24 hours-a-day at
1-800-777-4376.
Urgent Care
Urgent 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:
n Most broken bones
n Minor cuts
n Sprains
n Bruises
n Non-severe bleeding
n Most drug reactions
n Minor burns
If you need urgent care, call iCare Customer
Service at 1-800-777-4376. We will tell you
where you can get care. You must get urgent
care from iCare doctors unless you get our
approval to see a non-iCare doctor.
Remember, do not go to a hospital
emergency room for urgent care unless your
doctor tells you to go there.
After-Hours Service
For after-hours urgent or emergent care
inquiries, please call us at 1-800-777-4376
(TTY 1-800-947-3529) or 414-223-4847, and
follow the prompts to get you in contact
with a member of the care management
team.
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 Getting Medical Care When
You Are Away From Home
Follow these rules if you need medical care
but are too far away from home to go to your
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 young adults who are spending time
away from home with a parent or relative. Call
iCare at 1-800-777-4376 for approval to go to
a different doctor, clinic or hospital.
Care Outside of Wisconsin
If you travel outside of Wisconsin and need
emergency services, health care providers can
treat you and send claims to iCare. You will
have to pay for any service you get outside
the state if the health care provider will not
submit claims or accept iCares payment as
payment in full.
Emergency Services Outside the U.S.
Independent Care Health Plan does not cover
any service, including emergency services,
provided outside of the United States, Canada
and Mexico. If you need emergency services
while in Canada or Mexico, iCare will cover
the service only if the doctors 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
iCare if you receive any emergency services
outside of the United States.
Pregnant Women
and Deliveries
If you become pregnant, please let iCare 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 co-pays when you are pregnant.
Independent Care Health Plan has several
5 doctors specializing in Obstetrics and
Gynecology in our network. See your PCP or
an OB/GYN for checkups throughout your
pregnancy.
You must go to an iCare hospital to have your
baby. Talk to your 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. Because 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. Your iCare 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 iCare
approval.
When You May Be
Billed For Services
It 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
iCare providers 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.
Billing Members
Covered and Non-Covered Services
If you receive a bill for services, call our
Customer Service Department at 1-800-777-
4376. You do not have to pay for covered
services that are provided by a Medicaid SSI
certified provider and that iCare is required to
provide 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.
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.
Other Insurance
If you have other insurance in addition to
iCare Medicaid SSI, you must tell your doctor
or other provider. Your health care provider
must bill your other insurance before billing
iCare. If your iCare 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.
Services Covered by iCare
Independent Care is responsible for providing
all medically necessary covered services
under Medicaid SSI.
MENTAL HEALTH AND
SUBSTANCE ABUSE SERVICES
Independent Care provides mental health
and substance abuse (drug and alcohol)
services to all members. If you need these
services, call Customer Service.
If you or someone you know is thinking about
suicide, call 1-800-SUICIDE or 1-800-784-2433.
For more information, call Mental Health
America of Wisconsin at 414-276-3122.
The Federal Substance Abuse and Mental
Health Services Administrations Center for
Mental Health Services started the National
Suicide Prevention Lifeline at 1-800-273-TALK
(8255). Part of the National Suicide Prevention
Initiative, the lifeline offers help right away to
people thinking about ending their lives. The
goal is to reduce the number of suicides in
our nation. Crisis centers all across the U.S. are
taking part.
FAMILY PLANNING SERVICES
We provide confidential family planning
services to all members. This includes minors.
If you do not want to talk to your PCP about
family planning, call our Customer Service
Department at 1-800-777-4376. We will help
you choose an iCare family planning doctor
who is different from your PCP.
We encourage you to receive family planning
services from an iCare doctor. That way we
can better coordinate all your health care.
Federal law allows members to choose their
provider, including physicians and family
planning clinics, for reproductive care and
supplies. Therefore, you can also go to any
family planning clinic that will accept your
ForwardHealth card even if the clinic is not
part of iCare.
MAMMOGRAM PROGRAM
Independent Care and the Centers for Disease
Control and Prevention recommend that
female members age 40 and older have a
mammogram each year. A mammogram is a
great way to find breast cancer early. Talk to
your care coordinator or call Customer
Service at 1-800-777-4376 to learn more.
DENTAL SERVICES
Independent Care Health Plan provides all
covered dental services in Kenosha,
Milwaukee, Racine and Waukesha counties,
but you must go to an iCare dentist. See the
iCare Medicaid SSI Provider Directory or call
Customer Service at 1-800-777-4376 for the
names of our dentists.
As a member of iCare, you have a right to a
routine dental appointment within 90 days
after your formal request.
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 If you live in a county that is not listed, you
may get dental services from any dentist who
will accept your ForwardHealth ID card. Your
dental services are provided by the State, not
iCare.
Dental Emergency
A dental emergency is an immediate dental
service needed to treat dental pain, swelling,
fever, infection or injury to the teeth.
If you already have a dentist who is with
iCare:
n Call the dentists office.
n Identify yourself as having a dental
emergency.
n Tell the dentists office what the exact
dental problem is. This may be something like
a toothache or swollen face. Make sure the
office understands that you are having a
dental emergency.
nCall the States transportation provider at 1-
866-907-1493 or (TTY) 1-800-855-2880 if you
need help with transportation.
If you do not currently have a dentist who
is with iCare:
n Call iCare. Tell us that you are having a
dental emergency. We can help you get
dental services.
nCall the States transportation provider at
1-866-907-1493 if you need help with
transportation to the dentists office.
For help with a dental emergency, call
Customer Service at 1-800-777-4376. You
have a right to get treatment for your dental
emergency within 24 hours after receipt of
your request.
CHIROPRACTIC SERVICES
You may get chiropractic services from any
chiropractor who will accept your
ForwardHealth card if you are a Medicaid SSI
member. Your chiropractic services are
provided by the State, not iCare.
FLU SHOTS
Each fall, iCare works with your doctor to help
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The HealthCheck
Checkup Includes:
n Health and developmental history
(including anticipatory guidance)
n Unclothed physical examination
n Vision screening
n Hearing screening
n Dental screening and a referral to a
dentist beginning at age one
n Immunizations (shots) appropriate
for age
n Blood and urine lab tests (including
blood lead level testing when
appropriate for age)
you get a flu shot. Talk to your care
coordinator or call Customer Services at
1-800-777-4376 for more information.
HEALTHCHECK
HealthCheck is a preventive health checkup
program for members under the age of 21.
The HealthCheck program covers complete
health checkups. These checkups are very
important for those under the age of 21. The
doctor wants to see those under the age of
21 for regular checkups, not just when they
are sick.
The HealthCheck health program has 3
purposes:
1. To find and treat health problems 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 some
health care not otherwise covered.
The HealthCheck program covers the medical
care for health problems found during the
checkup including medical care, eye care and
dental care.
Call the States transportation provider at
1-866-907-1493 or (TTY) 800-855-2880 if you
need help with transportation for
HealthCheck visits.
To schedule a HealthCheck exam or for more
information call our Customer Service
Department at 1-800-777-4376.
TRANSPORTATION
The States transportation provider will
arrange all non-emergency transportation to
covered appointments for members who
have no other way to get to their
appointments. Please use the States
transportation provider toll-free telephone
number (1-866-907-1493) to arrange all of
your non-emergency medical transportation.
You must call 48 business hours in advance to
arrange for transportation, except in urgent
situations where same-day or next day
transportation can be arranged.
Transportation is authorized for Medicaid
covered services only. Please remember that
you must call for transportation at least two
business days before your visit for all routine
appointments.
AMBULANCE
Independent Care covers 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 Customer Service Department
at 1-800-777-4376 for approval.
PHARMACY BENEFITS
Your prescriptions and certain over-the-
counter items are provided by the State, not
iCare.
You may receive a prescription from an iCare
doctor, specialist or dentist. You can fill your
prescription at any pharmacy that is a
provider for Medicaid SSI.
Please show your ForwardHealth ID card to
the pharmacy when you get your
prescriptions filled. You may have
co-payments or have limits on covered
medications.
CARE COORDINATION
As a member of iCare, you will be asked to
speak to a trained staff member about your
health care needs. Your care manager/care
coordinator will contact you within the first
60 days of being enrolled with iCare 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
manager/care coordinator. If you have
questions or would like to contact iCare
directly to schedule a care evaluation session,
please call 1-800-777-4376.
HEALTH EDUCATION
Independent Care Health Plan believes in
more than just providing health care services.
We also want to teach our members how to
take care of themselves. We encourage
exercise, if your doctor allows it. We also
support healthy living through special health
education classes. To learn more, contact
iCare at 1-800-777-4376.
If You Move
If you are planning to move, contact your
county Department of Social or Human
Services and contact iCare at 1-800-777-4376.
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 iCares service area, call the
HMO Enrollment Specialist at 1-800-291-2002.
Independent Care 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.
Second Medical Opinion
A second medical opinion on recommended
treatments may be appropriate in some
cases. Contact your doctor or our Customer
8
 Service Department for information.
HMO Exemptions
An 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 Care
You have a right to accept or refuse medical
or surgical treatment. You also have a 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 feelings by
completing a living will or power of attorney
for health care form. Contact your doctor for
more information.
You have the 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.
Right to Medical Records
You have the right to ask for copies of your
medical record from your provider(s). We can
help you get copies of these records. Please
call 1-800-777-4376 for help. Please note: You
may have to pay for copies of your medical
record. You also may correct wrong
information in your medical records if your
doctor agrees to the correction.
iCares Member Advocate
Independent Care has a Member Advocate to
help you get the care you need. The Advocate
can answer your questions about getting
9
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.
External Advocate
If you have problems getting services while
you are enrolled with iCare for Medicaid SSI
services, call the SSI External Advocate at
1-800-708-3034.
State of Wisconsin
HMO Ombuds Program
The State has Ombuds 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 your HMO. The
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 an Ombuds.
Complaints,
Grievances and Appeals
We would like to know if you have a
complaint about your care at iCare. Please call
iCares Member Advocate at 1-800-777-4376
(TTY: 1-800-947-3529) if you have a
complaint. Or, you can write to us at:
Independent Care Health Plan
1555 N. RiverCenter Drive, Suite 206
Milwaukee, WI 53212
If you want to talk to someone outside of
iCare 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 iCare or to the Medicaid
SSI program.
The address to complain to the Medicaid SSI
program is:
Medicaid SSI
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.
We cannot treat you differently than other
members because you file a complaint or
grievance. Your health care benefits will not
be affected.
You 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 iCare. 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 the Medicaid SSI Ombuds
at 1-800-760-0001 or the HMO Enrollment
Specialist at 1-800-291-2002.
Physician Incentive Plan
You 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, call our Customer Service
Department at 1-800-777-4376 and request
information about our physician payment
arrangements.
Provider Credentials
You 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
1-800-777-4376.
Clinical Practice Guidelines
Independent Care 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. You can receive a hard copy
of our practice guidelines by contacting your
care coordinator or by visiting our website at
www.icare-wi.org.
iCares Quality
Improvement Program
Independent Care works to provide
medically-necessary health care that is
efficient, effective, safe, accessible,
accountable and fair. Our Quality
Improvement (QI) program provides structure
and processes that make it possible for iCare
to carry out our mission and commitment to
ongoing improvements to the quality of care
and services, availability and access to care
and health status of our members. It is a
program that changes with the changing
needs of our members and standards set by
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 the medical community and regulatory
agencies.
Customer Service
Our Customer Service Department is
available to assist you at 1-800-777-4376. If
you need help contacting your care
coordinator, call Customer Service.
Please have your ForwardHealth card
available when you call. Our Customer Service
staff will be asking you for your ID number
from your ForwardHealth card to look up your
member information in the iCare computer
system.
Member Rights
n You have the right to ask for an interpreter
and have one provided to you during any
Medicaid SSI covered service.
n You have the right to receive information
provided in this member handbook in
another language or another format.
n 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 days a week.
n You have the right to receive information
about treatment options including the right
to request a second opinion.
nYou have the right to request the results of
an External Quality Review study.
n You have the right to make decisions about
your health care.
n You have the right to be treated with
dignity and respect.
n You have the right to be free from any form
of restraint or seclusion used as means of
force, control, ease or reprisal.
Your Civil Rights
Independent Care provides covered services
to all eligible members regardless of:
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n Age
n Race
n Religion
n Color
n Disability
n Sex
n Sexual Orientation
n National Origin
n Marital Status
n Arrest or Conviction Record
n Military Participation
All medically necessary covered services are
available to all members. All services are
provided in the same manner to all members.
All persons or organizations connected with
iCare who refer or recommend members for
services shall do so in the same manner for all
members.
Translating or interpreting services are
available for those members who need them.
This service is free.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED
AND SHARED. IT WILL ALSO TELL YOU HOW
YOU CAN GET THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
The law says we must keep your health
information private. This Notice will tell you
what information we collect. It also will tell
you how we use it. You can call our Member
Services Department at 414-223-4847 if you
have questions about this Notice. If you do
not have any questions, you do not have to
do anything.
How We May Use or Share Your
Health Information
There are instances when the law allows us to
use and share your health information without
your written consent. The following is a list of
those times.
1. For Treatment. We may use your health
information to provide you with health care
treatment or services. We also use it to
arrange social services you may need. For
example:
Your care coordinator or case manager may
share information they got from you or your
healthcare providers with others involved in
your treatment, including other health care
providers. The information they share will be
used to help you get the services you may
need.
Your health information may be shared with
social service agencies. This information will
be used to help you get the services you may
need.
We may share your Medicaid ID number
with transport companies if we need to get
you a ride to your health care appointments.
We may have to share your health
information with health education programs
you need or are participating in.
2. For Payment Functions. We may use your
health information to pay for services you had
or to manage benefits. For example:
Your provider will submit a bill to iCare for
payment of services you received. This bill
shows your name and Medical Assistance
number. It may give the services you received
and what was wrong with you.
Information about you may be shared with
the State of Wisconsin. It may be used to see
if you can join iCare. It may be used to see if
you can get Medicaid or other program
benefits.
3. For Health Care Operations. Your health
information may be used or shared to carry
out benefit or service related activities. This
means that your health information may be
shared with our staff or others to:
Look at the quality of care you had;
Learn how to improve our services;
Provide case management services;
Provide care coordination services;
Resolve your complaint or grievance;
See how our employees are doing in
providing you with service;
4. For Appointments and Treatment
Choices. Your health information may be
used or shared to remind you of
appointments. It may also be used to tell you
about different ways you can be treated. Or, it
can be used to tell you about other health
and services that you might like.
5. To Family and Personal Representatives.
We may share your health information with a
relative, close personal friend or other person
who is involved in your care.
6. Business Associates. We work with others
outside of iCare to provide certain services.
These others are called business associates.
Your health information may be disclosed to
them so they can do the job we ask them to
do. They must also protect your health care
information. For example, we work with a
company to pay your claims.
7. As Required by Law. Your health
information may be used or shared as
required by any federal, state or local law. This
means that we may share information when:
Requested by a court for legal reasons;
Needed by public health and Food and Drug
Administration authorities;
Needed for administrative actions, such as
Fair Hearings;
8. Health Oversight Actions. Your health
information may be given to state or federal
agencies to do reviews or to check on our
licensure. This helps the government to see
what we are doing to meet civil rights or
other laws.
9. For Law Enforcement. Your health
information may be shared if the law says we
must. We will also share it if there is a valid
court order to help identify or find suspects,
persons hiding from the law or missing
persons.
10. For Serious Threats to Health or Safety.
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 Your health information may be shared in
order to prevent or lessen a serious threat to
your health or safety. It may also be shared if
there is a threat to the health and safety of
the public.
11. For the Countrys Safety. Your health
information may be shared for the safety of
the country. It may also be shared for
government benefit reasons.
12. To Jails or Prisons. We may need to share
your health information with jail or prison
staff if you become an inmate.
13. For Research. Your health information
may be used for research needs, but only
after steps are taken to protect your privacy.
We will ask for your permission if the
researcher asks for information that says who
you are or if the researcher will be giving you
care.
14. For Workers Compensation or Social
Security Reviews. Your health information
may be shared as needed to keep the laws
related to workers compensation. It may also
be shared to help decide if you can get social
security.
15. Coroners, Medical Examiners or Funeral
Directors. Health information may be shared
to help confirm the identity of a deceased
person.
16. Organ Donations. Information may be
given to agencies if you need an organ
transplant. It may also be shared with
agencies if you want to donate an organ.
17. Other Uses. At times we may need to use
or share your health information for other
reasons. Other uses and disclosures not
described in this Notice will be done only
with your consent. You may cancel your
consent, but it must be done in writing. When
you cancel your consent we will no longer be
able to use or share your health information
as stated in the consent. But, we will not be
13
able to take back any use or sharing that was
already made with your consent. You will be
told as soon as possible after the information
is shared.
Your Health Information Rights
All questions about your rights must be in
writing. You can send your written request to:
Member Advocate/Member Rights Specialist
Independent Care Health Plan
1555 N. RiverCenter Drive, Suite 206
Milwaukee, WI 53212
You can call our Member Advocate/Member
Rights Specialist to help make your request at
414 223-4847.
1. Request Limits: You can ask us to limit some
uses and sharing of your health information.
But the law does not say we must agree to
these limits, unless your request is to not
disclose protected health information about a
health care service you received that was paid
for in full by you or by another person (other
than an insurance company like iCare) on
your behalf.
2. Request That You be Informed About Your
Health in a Way or at a Location That Will Keep
Your Information Private: Your request will be
evaluated. We will let you know if it can be
done.
3. Inspect and Copy: You have the right to view
and copy certain health information about
you. In some cases you may request a review
if you are denied access to records. You may
be charged a reasonable fee if you want extra
copies of records.
4. Request a Change: You have the right to
request us to change your health information
that you believe is not correct or complete.
You must give a reason for your request. We
do not have to make the change. If we say no
to your request, we will give you information
about why we will not make the change and
how you can disagree with it.
5. Report of When Your Information Was
Shared: You can ask for a list of when and why
we shared your health information. This list
will only be for reasons other than treatment,
payment or health care operations. Your
request should specify a time period of up to
six years. It may not include dates before April
14, 2003.
6. Paper Copy: You can ask to get a paper copy
of this Notice at any time. Send a written
request to our Privacy Officer at 1555 N.
RiverCenter Drive, Suite 206, Milwaukee, WI
53212. You may also get a copy of this Notice
at our website: www.icare-wi.org.
Changes to this Notice of Privacy Practices
We have the right to change the terms of this
Notice at any time. The new Notice will be
effective for all health information we have.
Any changes to the Notice will be mailed to
you at the address you gave us. It will also be
posted to our website. Until changes are
made to the Notice, we will comply with this
version.
Complaints
You may complain to us if you believe your
privacy rights have been violated. Complaints
must be in writing. If you need help filing a
complaint, contact our Member
Advocate/Member Rights Specialist at 223-
4847. You will not be treated any differently if
you file a complaint.
Secretary of the Department of Health and
Human Services by writing to Office of Civil
Rights, Department of Health and Human
Services, 200 Independence Ave. SW,
Washington, D. C. 20201.
Our Responsibilities
We must:
Keep your protected health information
private.
Tell you about our legal duties and privacy
practices about your health information.
Stand by the terms of this notice.
Tell you if we cannot agree to a limit on how
you want your information used or disclosed.
Notify you if there has been a breach of your
protected health information.
Meet reasonable requests you may make to
send health information by other means or at
other locations.
Contact Information
If you have any questions or complaints,
please contact us at:
414-223-4847
Toll Free: 1-800-777-4376
TTY: 1-800-947-3529 or 7-1-1
Voice: 1-800-947-6444 or 7-1-1
Effective Date of this Notice: May 22, 2013

You may also file a complaint with the

My Health Care Contacts

My Care Coordinator is ____________________________________________________
Phone Number ________________________________________________
My Primary Care Physician is _______________________________________________
Phone Number ________________________________________________
My Dentist is ______________________________________________________________
Phone Number ________________________________________________

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 1555 N. RiverCenter Drive, Suite 206
Milwaukee, WI 53212
1-800-777- 4376
TTY 1-800-947-3529 or 7-1-1
www.icare-wi.org
www.icare-2b.org

www.facebook.com/IndependentCareHealthPlan