Mandatory Passages and Language for MC+ Managed Care Health Plan Handbook, page 15

Choosing And Changing Your Primary Care Provider (PCP)

You must choose a PCP. If you do not, we will choose one for you. Your PCP will manage your health care. The PCP knows your health plan network and can guide you to specialists if you need one. You may ask for a specialist as your PCP if you have a chronic illness or disabling condition. They will work out a plan to make sure you get the care you need.

You have a right to change PCPs in your MC+ Managed Care health plan at least two times per year. Children in state custody may change PCP's as often as needed. To do this, call your health plan.

If You Are Billed

Your health plan will pay for all covered MC+ Managed Care services. You should not be getting a bill if the medical service you got is a covered MC+ Managed Care benefit. If you choose to pay for a service, you must agree in writing that you will be responsible for the payment before getting the service.

You will not have to pay for covered health care services even if:

the State does not pay your MC+ Managed Care health plan.
your MC+ Managed Care health plan does not pay your provider.
your provider's bill is more than your MC+ Managed Care health plan will pay.
your MC+ Managed Care health plan cannot pay its bills.

If you get a bill, do not wait! Call your health plan. They will look into this for you.

You may have to pay for services you get if:

you go to another health care provider without a referral from your PCP.
you choose to get medical services that are not covered by MC+ Managed Care.
you go to a provider that is not your health plan's provider without prior approval.

Fraud And Abuse

Committing MO HealthNet fraud or abuse is against the law.

Fraud is a dishonest act done on purpose.

Examples of member fraud are:

Letting someone else use your MC+ Managed Care health plan card(s) or red MC+ card or
Getting prescriptions with the intent of abusing or selling drugs.

An example of provider fraud is:

Billing for services not provided.

Abuse is an act that does not follow good practices.

An example of member abuse is:

Going to the emergency room for a condition that is not an emergency.

An example of provider abuse is:

Prescribing a more expensive item than is necessary.

You should report instances of fraud and abuse to:

[Health Plan Name]
[Health PLAN PHONE NUMBER])

MO HealthNet Division
Participant Services
1 (800) 392-2161