ghcscw.comGroup Health Cooperative of South Central Wisconsin (GHC-SCW)Revised: 3/7/2019

POS

Group Health Cooperative of South Central Wisconsin

2019 Member Reference GuideVerona Area School District

Quick Reference Card in Back

To get the best care possible, we encourage you to take these quick steps!

1. Activate your online GHCMyChartSM account. Schedule appointments, refill your prescriptions, view select test results and more! Visit ghcscw.com/ghcmychart to get started.

2. Transition your care. If you’re coming to us from a different health care organization, we want to help make your transition as seamless as possible. You’ll want to complete a Transition of Care form and transfer existing:

• Medical records so we can better understand your medical history.

• Specialty care treatment so we can help provide continuity of your care.

• Medications so we can help you avoid gaps in your medication regimen.

3. Choose your Primary Care Provider (PCP). To view our PCPs, visit ghcscw.com and select, “Clinic or Provider.”

GET STARTED!

QUESTIONS? Call Member Services at (608) 828-4853 or toll free at (800) 605-4327.

CONNECT WITH US!

Welcome to Group Health Cooperative of South Central Wisconsin (GHC-SCW)!

Thank you for choosing GHC-SCW as your health care provider.

As a GHC-SCW member-owner, you play an active role in your health care, so it’s important that you stay up-to-date on what’s happening in your Cooperative. And as a non-profit, we’re focused on green initiatives that better our community which means connecting and communicating with you online. Stay connected and help us go paperless!

Sign-up today at ghcscw.com/ghcmychart to receive our member newsletter, HouseCall, and our regular electronic member communications.

Follow-us on Facebook and Twitter to get the most up-to-date information as it happens!

GET CARE!

QUESTIONS? Call Member Services at (608) 828-4853 or toll free at (800) 605-4327.

Your Primary Care Clinic

Your primary care clinic is your first point of contact for all your health care needs. Anytime you need medical care (except for emergencies), call your primary care clinic for an appointment or to speak with your PCP’s nursing staff.

GHC-SCW Urgent Care Clinic

Urgent care is for non-life-threatening conditions that need to be treated that same day or after business hours. These conditions typically cause unusual discomfort.

Physical therapy is available for some injuries at the GHC-SCW Urgent Care Clinic at Capitol Clinc.

Emergency Care

Emergency care is for life-threatening medical conditions (including severe symptoms) that can cause serious danger to your health.

If it is not possible to go to your designated hospital, go to the nearest hospital emergency room or call 911.

GHC-SCW Primary Care Clinics

Capitol Clinic: (608) 257-9700

East Clinic: (608) 222-9777

DeForest Clinic: (608) 846-4787

Hatchery Hill Clinic: (608) 661-7200

Madison College Community Clinic: (608) 441-3220

Sauk Trails Clinic: (608) 831-1766

Additional GHC-SCW Clinics

Capitol Regent Mental Health Clinic: (608) 441-3290

Complementary Medicine Central Clinic: (608) 662-5090

Princeton Club West PT/OT Clinic: (608) 662-5060

Examples of conditions include:

• Back Pain

• Ear Pain

• Colds and Flu

• Cuts, Scrapes or Bruises

• Eye Irritation

• Fever

• Migraine Headaches

• Sore Throats

• Simple Bone Fractures (not through skin)

• Sprains

• Skin Rashes

• Urinary Burning

Examples include:

• Alcohol or Drug Overdose

• Amputations or Severe

Lacerations

• Complex Bone Fractures (through skin)

• Complications During Pregnancy

• Facial or Eye Trauma

• Heart Attack/Chest Pain

• Knife/Gunshot Wounds

• Loss of Consciousness

• Poisoning

• Respiratory Problems

• Severe Burns

• Stroke

Contact the GHC-SCW Urgent Care Clinic at Capitol Clinic to schedule an appointment. Appointments are made to better serve your same-day access needs. Call the GHC-SCW Urgent Care Clinic at (608) 442-8100.

GET CARE!

QUESTIONS? Call Member Services at (608) 828-4853 or toll free at (800) 605-4327.

GHC NurseConnect

GHC NurseConnect is your 24/7 nurse advice line when you need general care advice over the phone. It’s staffed exclusively by GHC-SCW Registered Nurses - nurses you already know and trust. Call (608) 661-7350 or toll free at (855) 661-7350!

virtuwell

Get better faster and save a trip to the clinic. Visit virtuwell, your 24/7 online clinic, where you can get a diagnosis and treatment plan in just a few minutes. Visit ghcscw.com/virtuwell to learn more.

Behavioral Health

We offer a full range of mental health, addiction services and health behavior interventions for children, adolescents and adults. Members can access GHC-SCW mental health services directly, without referral, by contacting any GHC-SCW clinic. Substance use and addiction services are provided by our UW Health partner, UW Health Behavioral Health and Recovery. Call (608) 282-8270 to contact them directly without a referral.

Primary Care Behavioral Health

At GHC-SCW, we believe in caring for your mind, body and spirit. Our PCPs and Behavioral Health Providers work together to support your overall physical and emotional health and well-being by offering easy-to-access behavioral health consultations in your GHC-SCW primary care clinic.

Eye Care

GHC-SCW optometry schedules are open six months in advance, so contact them early to get a time that fits your schedule. Make an appointment through GHCMyChartSM or call (608) 257-7328.

For Urgent and Emergency Mental Health Crisis

For immediate help with an urgent mental health crisis, 24-hour crisis intervention services are available for GHC-SCW members. You will be assisted by a nurse or an on-call crisis counselor who will help you address your most pressing concerns, your safety and your follow-up service needs.

If you are considering suicide, call the GHC-SCW Urgent Care Clinic 24 hours a day at (608) 442-8100.

If your situation is immediately life-threatening, please call 911 or safely get yourself to the nearest hospital emergency room.

Physical and Occupational Therapy (PT/OT)

Our PT and OT staff work directly with your PCP to make sure that you are receiving comprehensive treatment for your injury or condition. Call (608) 662-5060 to schedule a standard PT/OT appointment. Call (608) 442-8100 to schedule an Urgent Care PT/OT appointment.

GHC-SCW Pharmacies

Conveniently refill your medications at our GHC-SCW Pharmacies using GHCMyChartSM. Our pharmacies are non-profit and offer competitive prices. Our pharmacy staff takes time to answer your questions and work closely with your GHC-SCW provider to coordinate your treatment.

Capitol Clinic: (608) 257-9732 Hatchery Hill Clinic: (608) 661-7242 Sauk Trails Clinic: (608) 257-4869

QUESTIONS? Call Member Services at (608) 828-4853 or toll free at (800) 605-4327.

IMPORTANT CONTACT INFORMATION!

GHC-SCW Member Services

Our Member Services team can help you with questions or concerns about your medical care and insurance coverage. Call (608) 828-4853 or toll-free at (800) 605-4327 and request Member Services.

Email: member_services@ghcscw.com En Español: (855) 243-8454 Interpreter Services: (608) 661-7215

Care Management

Prior authorizations, coordination of care, continuing care and durable medical equipment needs should be directed to the GHC-SCW Care Management department. The GHC-SCW Care Management department should also be contacted within 48 hours whenever emergency services have been provided. Call the GHC-SCW Care Management department at (608) 257-5294.

Claims

Claims or unpaid bills should be directed to the GHC-SCW Claims department. Bills for services provided can be mailed to the GHC-SCW Administrative Office. Please include your member number. Call the GHC-SCW Claims department at (608) 251-4526.

Coordination of Benefits

Questions about other coverage in addition to your GHC-SCW plan (i.e., secondary insurance, Medicare, Medicaid) should be directed to the GHC-SCW Coordination of Benefits Department. Call GHC-SCW Coordination of Benefits at (608) 251-4156 x4269.

Enrollment

Questions about the status of a submitted application or requests for an identification card should be directed to the GHC-SCW Enrollment department. Call the GHC-SCW Enrollment department at (608) 260-3170.

Patient Financial Coordinator

The Patient Financial Coordinator can help you estimate out-of-pocket costs for services rendered at GHC-SCW clinics based on your individual insurance plan. Email pfc@ghcscw.com or call (608) 662-4990.

Privacy

We promise you that GHC-SCW staff is committed to protecting the privacy and security of your health information. For questions related to privacy, call the Ethics and Fraud Reporting Hotline at (844) 480-0055.

Administrative Offices

1265 John Q. Hammons Drive, Suite 200 Madison, WI 53717-1962 Phone: (608) 251-4156

Medical Billing

Questions about medical bills or unpaid bills for services rendered at one of our GHC-SCW Clinics, questions about subrogation claims and questions about workers compensation claims should be directed to our medical billing department. Bills for services provided can be mailed to the GHC-SCW Administrative Office. Please include your member number. Call GHC-SCW Medical Billing at (608) 251-4138.

Premium Billing

For premium billing questions for individual or group plans, call (608) 251-4156 x4587.

MK17-113-1(9.18)FL

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK19-11-01(2.19)FL

Group Health Cooperative of South Central Wisconsin (GHC-SCW)YOUR LOCAL, NON-PROFIT, MEMBER-OWNED, HEALTH CARE COOPERATIVE

ghcscw.com

GHC-SCW isn’t your standard health care company. We exist to serve our members, and we value our cooperative spirit. We pioneered the HMO movement as Dane County’s first HMO, and today we are a nationally-recognized leader in health care with a history of many other trailblazing firsts. We provide the entire spectrum of managed health care services, including insurance, primary care and select specialty care, in six Madison-area clinics. From our commitment to a non-profit, member-owned cooperative care model to the investments made in the benefits and the well-being of our employees, we believe in the culture of exceptional care.

LEARN MORE AT GHCSCW.COM

Our MissionOur mission is to provide accessible, comprehensive, high-quality health care and outstanding service in an efficient and personalized manner.

Our VisionGHC-SCW will be a leader among health plans in providing high quality medical care, impeccable service and competitive benefit levels and premium rates. GHC-SCW will maintain consistent membership growth and a sound financial return each year.

Our ValuesOur success is driven by an unwavering belief in five common values which guide our work and shape the way we behave each day to deliver the best possible member experience. 

• Patient-centered• Community involved• Non-profit cooperative• Innovative• Quality-driven

Our BeliefsIn the ever-changing health care landscape we are committed to diversity, inclusion and equity.

• We believe health care is ahuman right.

• We believe in treating allpeople with dignity andrespect.

• We believe there is strengthin diversity.

• We believe equitycelebrates our humanity.

Our Commitment to ExcellenceEvery day, we strive to be and do the very best for our members. GHC-SCW is one of just two health plans in the nation to receive a rating of 5 out of 5 in NCQA’s Private Health Insurance Plan Ratings 2018–2019 and we’re Wisconsin’s first and only health plan to receive NCQA’s highest rating.*

*National Committee for Quality Assurance (NCQA) Private Health Insurance Plan Ratings 2018–2019.

Get to know

The GHC Experience GuaranteeSM

What is the GHC Experience GuaranteeSM? The GHC Experience GuaranteeSM is a promise that every patient and member gets the best experience every time. Starting August 31, 2018, if you have an experience at a GHC-SCW clinic that fails to meet your expectations in any way, you can visit GHCSmartCare.com to download the GHC Experience GuaranteeSM App. Using the app, you can tell us about your experience and at your request, we will refund some or all of your out-of-pocket costs associated with the visit.

Why has GHC-SCW decided to launch the GHC Experience GuaranteeSM? For the last two decades, GHC-SCW has earned an “Excellent” accreditation status from the National Committee for Quality Assurance (NCQA). We’re the only clinics in the area with Level 3 Patient-Centered Medical Home recognition and we’re continuously one of the highest-rated health insurance plans in the nation. We’re confident that we’re providing the very best care in Wisconsin – so confident that we’re willing to stand behind it with a money-back guarantee. We think our members deserve that. After all, in every other industry, customers have the opportunity to get a refund when they’re unsatisfied – we are proud to set the standard for customer service in health care.

How does the GHC Experience GuaranteeSM App work? Starting August 31, 2018, if you have an experience at a GHC-SCW clinic that fails to meet your expectations, visit GHCSmartCare.com, tap the app to download and tell us about it. Using the app, you can request a refund for some or all of your out-of-pocket costs (up to $2,000). You trusted us with your care, so we will trust you to tell us what your experience was actually worth. The app is compatible with all devices and the form takes just moments to complete.

What does the GHC Experience GuaranteeSM cover and when am I eligible? Your refund request must be made no more than six months after your date of service. The GHC Experience GuaranteeSM only covers visits to GHC-SCW clinics or providers that occurred on or after August 31, 2018.

What can I expect once I submit my feedback through the GHC Experience GuaranteeSM App? If you have requested to talk to us or have requested a refund, you will receive a call from our Member Experience Team within three business days. They will speak with you on the phone and help process your refund if needed. If you requested to have some or all of your out-of-pocket costs refunded (up to $2,000), the Member Experience Team will work with you to be sure it is returned to you through your original method of payment within five business days.

What is not covered through the GHC Experience GuaranteeSM?

• Visits to any non-GHC-SCW clinics including UW Health,University Hospital or Regional Network Providers.

• Disagreements with your provider’s medical opinion, medicaldecision-making or refusal to provide or prescribe a particularmedication.

If I use the GHC Experience GuaranteeSM App, will my private health information be safe? Yes, bank-grade security protocol is in place to safeguard your privacy and personal health information. We will never share your private health information with any outside organizations.

What will you do with the information collected in the GHC Experience GuaranteeSM App? We’re always looking for ways to learn from and engage with our members. All feedback – positive and negative – collected through the GHC Experience GuaranteeSM App will be reviewed and analyzed to help us improve our Cooperative. Your feedback will not be connected to your medical record.

What should I do if I have additional questions about the GHC Experience GuaranteeSM? We’ve formed a Member Experience Team that can answer your questions and guide you through the GHC Experience GuaranteeSM App if needed. To speak with our Member Experience Team, call (608) 828-4853 or toll free at (800) 605-4327.

ghcscw.comGroup Health Cooperative of South Central Wisconsin (GHC-SCW)

MK18-80-1(1.19)FL

DANE COUNTY

IOWA COUNTY

SAUK COUNTY COLUMBIA COUNTY

JUNEAU COUNTY

GHC-SCW HMO NETWORK

FIND A PROVIDER

Group Health Cooperative of South Central Wisconsin (GHC-SCW) MK19-03-0(1.19)FL

LEGEND

Hospital and Primary Care Clinic Location

Primary Care Clinic Location Only

Hospital Location Only

SELECT A PROVIDER

Visit ghcscw.com and select “Search for a Clinic or Provider.”

Indicate your chosen provider and clinic on your GHC-SCW insurance application or call Member Services at (608) 828-4853 or toll-free at (800) 605-4327 and request Member Services.

Madison

Prairie du Sac Lodi

Portage

Oxford

Necedah

New Lisbon

Elroy

Reedsburg Wisconsin Dells

Plain

Spring Green Mazomanie

Cross Plains

DeForest

Verona

Belleville

Dodgeville

Mineral Point

Montfort

Highland Barneveld

Mount Horeb Fitchburg

Stoughton

Cottage Grove

Pardeeville

Sauk City

Mauston

PRIMARY CARE CLINICS

COLUMBIA COUNTY

Lodi

• Lodi Clinic – Sauk Prairie Healthcare

Pardeeville

• Pardeeville Clinic –Divine Savior Healthcare

Portage

• Portage Clinic – Divine Savior Healthcare

DANE COUNTY

Belleville

• Belleville Clinic –UW Health Family Medicine

Cottage Grove

• Cottage Grove Clinic – UW Health

Cross Plains

• Cross Plains Clinic – UW Health

DeForest

• GHC-SCW DeForest Clinic

Fitchburg

• GHC-SCW Hatchery Hill Clinic

Madison

• GHC-SCW Capitol Clinic

• GHC-SCW East Clinic

• GHC-SCW Madison CollegeCommunity Clinic

• GHC-SCW Sauk Trails Clinic

• Joyce and Marshall Erdman Clinic –Access Community Health Centers

• Northeast Family Medical Center –UW Health Family Medicine

• William T. Evjue Clinic –Access Community Health Centers

• Wingra Family Medical Center –Access Community Health Centers

Mazomanie

• Wisconsin Heights Clinic –Sauk Prairie Healthcare

Mount Horeb

• Mount Horeb Clinic – UW Health

• UHH Clinic – Mount Horeb

Stoughton

• UW Health Stoughton Clinic

Verona

• Verona Clinic –UW Health Family Medicine

GRANT COUNTY

Montfort

• UHH Clinic – Montfort

IOWA COUNTY

Barneveld

• UHH Clinic – Barneveld

Dodgeville

• Dodgeville Medical Center of UHH

Highland

• UHH Clinic – Highland

Mineral Point

• Mineral Point Medical Center of UHH

JUNEAU COUNTY

Elroy

• Elroy Family Medical Clinic

Mauston

• Mile Bluff Clinic

Necedah

• Necedah Family Medical Clinic

New Lisbon

• New Lisbon Family Medical Clinic

MARQUETTE COUNTY

Oxford

• Crossroads Clinic –Divine Savior Healthcare

SAUK COUNTY

Plain

• Plain Clinic – Sauk Prairie Healthcare

Reedsburg

• Reedsburg Area Medical CenterPhysicians Group

Sauk City

• Prairie Clinic – Sauk Prairie Healthcare

Spring Green

• River Valley Clinic – Sauk PrairieHealthcare

• UHH Clinic – Spring Green

Wisconsin Dells

• Delton Family Medical Center

COLUMBIA COUNTY

Portage

• Divine Savior Hospital

DANE COUNTY

Madison

• UnityPoint Health - Meriter

• UW Health at The American Center

• University Hospital

IOWA COUNTY

Dodgeville

• Upland Hills Health Hospital

JUNEAU COUNTY

Mauston

• Mile Bluff Medical Center

SAUK COUNTY

Reedsburg

• Reedsburg Area Medical Center

Prairie du Sac

• Sauk Prairie Hospital

HOSPITALS

Visit ghcscw.com

Find the most current information about our wide-selection of providers and clinics at ghcscw.com. Important contact information such as phone numbers and locations are listed on our website.

For a printed copy of our provider directory, please call Member Services at (608) 828-4853 or toll-free at (800) 605-4327 and request Member Services.

ghcscw.com

GHC-SCW Complementary Medicine

Traditional and Non-Traditional Medicine Working TogetherAt GHC-SCW, we believe in a holistic approach to wellness. We complement traditional medicine with alternative care like therapeutic sessions and group classes. Reach your highest health potential with the GHC-SCW complementary medicine program – the first of its kind in Dane County!

Therapeutic Sessions

Complementary medicine therapeutic sessions are one-on-one sessions available by appointment. They’re open to all GHC-SCW members, no referral needed. Please refer to your Benefits Summary and Member Certificate for benefit details.

Acupuncture is a traditional Chinese therapy that uses thin needles to help stimulate the body’s natural ability to heal.

Aroma Mind/Body Care uses light touch, aromatherapy and more to promote relaxation and reduce tension or stress.

Craniosacral Therapy is a light touch therapy using mostly stationary hand placements to bring balance to the body by releasing pain, stress and trauma.

Infant Massage Therapy uses light touch to strengthen the bond between parent and child.

Manual Lymph Drainage is a gentle technique to assist in boosting the immune system and increase lymph production.

Massage Therapy therapeutic techniques promote relaxation, sooth tension and aid in pain reduction by pressing and kneading muscles and soft tissues.

Myofascial Massage releases body tissues to help increase functioning after an injury or the onset of pain.

Naturopathic Medicine combines herbal medicine, nutrition and other therapies for natural healing.

Oncology Care works with conventional cancer care by incorporating the healing therapies of massage, acupuncture, reiki and more.

Reflexology uses pressure on the foot to help relieve pain and other symptoms.

Reiki Therapy uses light touch to lower stress, enhance relaxation, relieve pain and increase self–awareness.

Thai Massage involves a practitioner that moves your body into comfortable, yoga-like stretches for total body relaxation.

Get Started!To schedule an appointment, visit ghcscw.com and log in to your GHCMyChartSM account or call (608) 662-5090.

Get Started!Join a class that’s right for

you! To register and view

discounted member rates,

visit ghcscw.com, select

“Wellness,” then click

“Sign Up for Classes” or

call (608) 662-5090.

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK18-25-0(5.18)

ghcscw.com

GHC-SCW Complementary Medicine

Group Classes

Aromatherapy classes teach the Aromatherapy basics including the benefits of different essential oils, as well as how to safely create Aromatherapy. Participants will have the opportunity to create their very own blend.

Belly Dance/Zumba classes use a timeless style of dance with elegance and passion. Isolation of the chest, tummy and hip muscles while dancing creates fluidity and a vigorous toning and cardio workout.

Fall Prevention classes teach participants a variety of techniques to prevent falls including yoga, tai chi, ballroom dancing and more.

Mindfulness Meditation can help relax the body and mind, increase calmness and improve psychological balance. Techniques include postures, focused attention and an open attitude toward distractions.

Tai Chi is a slow-moving martial art practice that combines mind, breath and action to increase flexibility, strengthen the body, restore balance and generate peace of mind.

Yoga classes utilize postures, breathing techniques and meditation to improve your overall health and well-being. Relax, recharge and restore with any of our yoga class levels.

Complementary Medicine Locations

1. Complementary Medicine Central Clinic 740 Regent St., Suite 106

Madison, WI

2. East Clinic 5249 E. Terrace Dr.

Madison, WI

3. Hatchery Hill Clinic 3051 Cahill Main

Fitchburg, WI

4. Madison College Community Clinic 1705 Hoffman St.

Madison, WI

5. Sauk Trails Clinic 8202 Excelsior Dr.

Madison, WI

3 a.m. and a crying baby? Unsure about an unexpected rash? Busy schedules don’t always allow time for doctor’s visits. Call GHC NurseConnect, staffed 24/7 by local GHC-SCW nurses. They can answer your questions, pull up your medical records and even schedule a time for you to see your provider.

Get general care advice for:

• Cough

• Cold

• Fever

• Flu

• Sore Throat

• And more!

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK17-85-0(6.17)FL

ghcscw.com

GHC NurseConnect Your 24/7, local nurse line.

At GHC-SCW, we believe that when we work with our members to provide exceptional, complete and connected health care we are BETTER TOGETHERSM.

Pick Up The Phone!

Call: (608) 661-7350 or toll-free at (855) 661-7350 to speak with a GHC-SCW nurse today!

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK17-88-0(6.17)FL

ghcscw.com

Get Better, Faster 24/7 online clinic ghcscw.com/virtuwell

Visit GHC’s 24/7 online clinic, virtuwell,and get a diagnosis and prescription in just minutes.

As easy as 1, 2, 3...

Why People Love virtuwell

As a GHC-SCW member, you get three free visits to virtuwell per member per plan year! Every visit after that is just $49.

Prescriptions delivered to any pharmacy.

100% guaranteed or your money back.

Real people treat you, really fast!

You can use virtuwell anywhere, even on vacation!

If you have a sick child, there’s no need to drive them to a clinic across town.

98% of customers recommend us!

1. Visit ghcscw.com/virtuwell. Describe yoursymptoms in a simple online interview.

2.treatment plan, with prescriptions if necessary,and notify you within 30 minutes by email or text.

3. You feel better, faster!

Common Symptoms Treatedvirtuwell treats over 60 common conditions, including:

• Allergies

• Bladder Infection

• Burns

• Cold & Cough

• Cold Sores

• Flu

• Pink Eye

• Rashes

• Sinus Infection

• Yeast Infection

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK17-188-0(11.17)FL

ghcscw.com

When you and your provider collaborate on your health care, you are BETTER TOGETHERSM. With an online GHCMyChartSM account, you have access to smart, secure and simple tools that allow you and your provider to better manage your health, together.

Features

Message your provider.

Refill medications.

Schedule appointments online.

View and pay your bill.

View select test results, immunization records and health summaries.

Connect to your children’s medical and insurance information with GHCFamilyChart.

GHCMyChartSM is available as an app on your smartphone.

Get Started!

1. Visit ghcscw.com/ghcmychart and select “Register & Activate.”

2. Select “Request a Code Now!” and follow the prompts.

Smart. Secure. Simple.GHCMyChartSM

Manage your health information with one account! If you get care from several different care providers, you may have multiple MyChart accounts.

There’s good news! You can now use MyChartCentral and Lucy to house your GHCMyChartSM account and any other MyChart account you might have. That means you’ll use a single username and password to log in to one account where you can view and manage all your health information.

Log in to your GHCMyChartSM account and select “MyChartCentral” to get started!

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK18-26-0(5.18)FL ghcscw.com

Healthy Lifestyle. Healthy Rewards.

You can get up to $100 each calendar year for completing any of the GHC-SCW Wellness Reimbursement program activities listed below!

For more information, details and requirements for your Wellness Reimbursement program submission, visit ghcscw.com/wellness/wellness-reimbursement.

Athletic Shoes Receive a $25 reimbursement for athletic shoes purchased at Berkeley Running Company, Endurance House, Fleet Feet Sports, Morgan’s Shoes, Movin’ Shoes, or The Shoe Box/The Bargain Box. In addition, enjoy in-store athletic shoe discounts for GHC-SCW members.

Community Events Participate in any race, ride or walk for the community!

Submitting for Reimbursement

1. Log on to your GHCMyChartSM account, selectWebMD® and click on “Wellness Reimbursement.”

Don’t have GHCMyChartSM? Visitghcscw.com/ghcmychart and click “Register &Activate” to get started.

2. Complete the online Wellness Reimbursement form.

• Select the wellness reimbursement activityyou completed from the drop-down menu.

• Make sure activity criteria are met by filling inyour activity details.

• Upload required proof of participation and/orproof of payment.

3. Submit for reimbursement. You will receive anemail and confirmation that we received yourmaterials. Checks are issued every three months.

Community Classes/Leagues Take a GHC-SCW class, a community class or participate in a sports league (eg: frisbee, golf, etc.).

Community Supported Agriculture (CSA) Purchase a share of fruit or vegetable crops directly from a local farmer. You may choose to use csacoalition.org to find a CSA near you.

Doula Services Choose a certified doula to work with you through your pregnancy.

Exercise for Excellence Complete at least 120 workouts during the calendar year at a fitness club where you have a paid membership.

Weight Management Participate in Jenny Craig, Weight Watchers, or Healthy Woman for a minimum of three months. Program participation can take place in-person or online.

Date of Submission* GHC-SCW Sends Checks

First Quarter Jan. 1 – March 31 Mid May

Second Quarter Apr. 1 – June 30 Mid August

Third Quarter Jul. 1 – Sept. 30 Mid November

Fourth Quarter Oct. 1 – Dec. 31 Mid February

*If you are submitting a reimbursement request for a future event,the check will not be sent until the quarter following the event.

The deadline for submitting a reimbursement form is January 15 of the following year after a program has been completed.

Group Health Cooperative of South Central Wisconsin (GHC-SCW)MK18-26-0(5.18)FL ghcscw.com

Frequently Asked Questions

Who is eligible for the Wellness Reimbursement program?All enrolled GHC-SCW members age 18 and older are eligible to participate in the Wellness Reimbursement program. Members under 18 years of age are eligible for the $25 athletic shoe reimbursement only.

How much can I be reimbursed? How much can my family be reimbursed?Each GHC-SCW member who is 18 years of age or older can be reimbursed up to $100 per person with a maximum reimbursement of $200 per household, per calendar year. Members under 18 years of age are eligible for the athletic shoe reimbursement only with a maximum of $25 per calendar year.

Why do I submit my wellness reimbursement through GHCMyChartSM?GHCMyChartSM is a private and secure hub for online tools at GHC-SCW. GHCMyChartSM also allows you to review your personal health record if you visit a GHC-SCW clinic.

Can I get a wellness reimbursement if I do not have a GHCMyChartSM

account?Yes, you may submit for a wellness reimbursement by completing the Wellness Reimbursement form and mailing it in.

Can I submit for more than one Wellness Reimbursement Activity?Yes, members over the age of 18 may submit reimbursement for more than one wellness activity per calendar year for a total of $100 per person with a maximum reimbursement of $200 per household.

When do I need to turn in my Wellness Reimbursement form?Services must be obtained during the calendar year. The deadline for submitting a reimbursement form is January 15 of the following year after a program has been completed. You may submit reimbursement as soon as all the requirements have been met.

Can I purchase my CSA early for the upcoming year?Yes, you can purchase a CSA share early for the upcoming year, but you must submit for reimbursement only during the year in which you receive the shares.

What community events are eligible for a wellness reimbursement?Any race or walk you participate in around the country is eligible for the community event Wellness Reimbursement program. Just submit your proof of registration.

Does my fitness center or health club have to be approved?No. As long as you are a member of a fitness center or health club you are eligible for reimbursement! You just need to provide proof of 120 workouts.

Does it matter which doula I use?The doula must be certified to be eligible for reimbursement. Check out dona.org to find a certified doula near you.

Which weight management programs are eligible for reimbursement?GHC-SCW will reimburse you for your participation in Weight Watchers, Jenny Craig, or Healthy Woman. Participation can take place in-person or online. GHC-SCW will reimburse for program fees only and does not include reimbursement for any food or products purchased.

Who do I contact with questions about my wellness reimbursement?Call GHC-SCW Member Services at (608) 828-4853 or email wellness@ghcscw.com with your questions regarding the Wellness Reimbursement program.

Important DetailsGHC-SCW members who get their insurance plan through a federal government employer are not eligible for the wellness reimbursement program.

The Wellness Reimbursement Program is considered taxable income during the year of payment. If you have GHC-SCW insurance coverage through your employer, your employer may deduct taxes out of your paycheck.

You must have GHC-SCW insurance coverage at the time of the activity completion to be eligible for reimbursement.

POS Benefit Summaries

Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Primary Care Office Visits No $20 10% after Deductible Example: Office visits with Your Primary CareProvider (PCP)

Chiropractic Office Visits No $20 10% after DeductiblePreventive Health Examinations No No Charge 10% after Deductible Coverage is limited to USPSTF guidelines and

Women's Preventive HealthSpecialist Care Office Visits Yes $20 10% after Deductible Example: Autism Spectrum Specialist Office VisitPreventive Immunizations No No Charge 10% after Deductible Coverage is limited to USPSTF guidelines and

Women's Preventive HealthPrenatal and Postnatal Maternity Care No No Charge 10% after Deductible Coverage is limited to USPSTF guidelines and

Women's Preventive HealthDiagnostic X-Ray and Laboratory Tests Yes No Charge after

DeductibleNo Charge after

DeductibleExamples: Lab tests, blood work, or x-rays ordered byYour Provider; Prior Authorization is not requiredwhen routine labs and x-rays are performed at YourPrimary Care Provider's clinic

Advanced Radiology Yes No Charge afterDeductible

No Charge afterDeductible

Examples: CT, PET Scans, MRIs

Emergency and Urgent Care Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Urgent Care Visits No $20 $20Emergency Ambulance Service(air/ground)

No No Charge afterDeductible

No Charge afterDeductible

Coverage is limited to emergency care

Emergency Room Visits No $100 $100 Coverage is limited to emergency care; Copaymentwaived if admitted as a hospital inpatient

Prescription Drugs Tier You Pay In-Network You Pay Out-of-Network Benefit Notes

Outpatient Prescription Drugs onGHC-SCW Formulary Prior Authorizations, quantity limits,step therapy, age restrictions andother limits may apply

Tier 1 $0 Not Covered Covers up to a 30-day supply; 31-90 day supplyavailable for multiple Copays - subject to a maximumcost limit

Tier 2 $5 Not Covered Covers up to a 30-day supply; 31-90 day supplyavailable for multiple Copays - subject to a maximumcost limit

Tier 3 50% Copayment ($75min/$150 max)

Not Covered Covers up to a 30-day supply; 31-90 day supply notavailable

Tier 4(Specialty)

50% Copayment ($75min/$150 max)

Not Covered Covers up to a 30-day supply; 31-90 day supply notavailable

The Prescription Drugs Benefit is administered by GHC-SCW Clinic pharmacies and Navitus. Prescription Drugs are NOT COVERED outside of the GHC-SCWnetwork of providers. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, seewww.ghcscw.com.

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Diabetic Disposable Supplies No 20% up to maximum Not Covered Member pays Coinsurance up to $250 maximumDurable Medical Equipment Yes 20% Not CoveredHearing Aids for Members age 18 andover

Yes 20% Not Covered Limited to one hearing aid per ear per 36 months;GHC-SCW coverage is for the basic model only

Hearing Aids for children age 17 andunder

Yes No Charge Not Covered Limited to one hearing aid per ear per 36 months;GHC-SCW coverage is for the basic model only

$20 Copayment $100 Deductible 100/90 POS Plan

Plan Number: 1904720Benefits Accumulate on a Plan Year.

Policy CoinsuranceIn-Network: 0%Out-of-Network: 10%

MEMBER FAMILY

In-Network Deductible $100 $300Out-of-Network Deductible $200 $600

Medical In-Network Maximum Out-of-Pocket (MOOP) $200 $600Pharmacy In-Network Maximum Out-of-Pocket (MOOP) $2,000 $4,000

Out-of-Network Maximum Out-of-Pocket (MOOP) $400 $1,200

CSC16-25-01-1(06/16)C 2019 Benefit Summary (Page 1 of 3) POS-1904720-RSPri nte d: 6/6/2019 - 3:43 PM

Cochlear Implants and BoneAnchored Hearing Aids for childrenage 17 and under

Yes No Charge afterDeductible

10% after Deductible

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospital Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Inpatient Hospital Services: PhysicianServices, Surgery, Facility Fees

Yes No Charge afterDeductible

10% after Deductible

Outpatient Hospital Surgical/Non-Surgical Services, Facility Fees

Yes No Charge afterDeductible

10% after Deductible Certain oral surgeries do not require PriorAuthorization

Skilled Nursing Facility Services Yes No Charge afterDeductible

10% after Deductible Limited to 100 Skilled Days per Member per year

Vision Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Vision Examinations No No Charge Not Covered Vision examinations must be provided by an In-Network Provider; Limited to one eye exam perMember per year

Mental Health & SubstanceUse Disorder Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Mental Health/Substance UseDisorder Outpatient Services

Yes $20 10% after Deductible Prior Authorization is not required when services areprovided at a GHC-SCW Clinic or at UW HealthBehavioral Health and Recovery Clinic

Mental Health/Substance UseDisorder Inpatient Services

Yes No Charge afterDeductible

10% after Deductible

Mental Health/Substance UseDisorder Transitional Services

Yes No Charge afterDeductible

10% after Deductible

Complementary MedicineServices Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Acupuncture (Initial Visit) No $75 Not Covered $45 per visit for follow up visits of Acupuncture;Coverage at GHC-SCW Clinics only

Naturopathy (Initial Visit) No $75 Not Covered $45 per visit for follow up visits of Naturopathy;Coverage at GHC-SCW Clinics only

Massage Therapy No $45 Not Covered 60-minute session; Coverage at GHC-SCW Clinics onlyMassage Therapy No $23 Not Covered 30-minute session; Coverage at GHC-SCW Clinics onlyReiki Therapy No $45 Not Covered 60-minute session; Coverage at GHC-SCW Clinics only

Dental Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Accidental Dental No No Charge afterDeductible

10% after Deductible Initial repair of accidental injury to sound and naturalteeth

Oral Surgeries Yes No Charge afterDeductible

10% after Deductible Certain oral surgeries do not require PriorAuthorization

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospice Yes No Charge afterDeductible

10% after Deductible Example: End of Life Services

Home Health Services Yes No Charge afterDeductible

10% after Deductible Limited to 60 visits per Member per year

$20 Copayment $100 Deductible 100/90 POS Plan

Plan Number: 1904720Benefits Accumulate on a Plan Year.

Policy CoinsuranceIn-Network: 0%Out-of-Network: 10%

MEMBER FAMILY

In-Network Deductible $100 $300Out-of-Network Deductible $200 $600

Medical In-Network Maximum Out-of-Pocket (MOOP) $200 $600Pharmacy In-Network Maximum Out-of-Pocket (MOOP) $2,000 $4,000

Out-of-Network Maximum Out-of-Pocket (MOOP) $400 $1,200

CSC16-25-01-1(06/16)C 2019 Benefit Summary (Page 2 of 3) POS-1904720-RSPri nte d: 6/6/2019 - 3:43 PM

Health Counseling Education No No Charge 10% after Deductible Coverage is limited to USPSTF guidelines andWomen's Preventive Health

Infertility Services No 50% up to maximum 50% up to maximum Lifetime Benefit maximum payment of $2,000 byGHC-SCW, which is accrued by GHC-SCW paying 50%Coinsurance of the first $4,000 of Infertility Services

Speech Therapy Yes No Charge afterDeductible

10% after Deductible Includes Rehabilitation Therapy; Limited to 20 visitsper Member per year

Cardiac Rehabilitation Therapy Yes No Charge afterDeductible

10% after Deductible Limited to 36 visits per Member per year

Outpatient Rehabilitation Therapy Yes No Charge afterDeductible

10% after Deductible Includes Physical and Occupational Therapy; Limitedto 40 combined visits per Member per year; SeeCertificate for additional information

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Benefit Summary NotesOffice Visit Copayments are waived for children under age 19.

Prior AuthorizationsPrior Authorization is required when services are not provided in a primary care setting by an In-Network Provider. Call (608) 257-5294 for Prior

Authorization. Failure to obtain Prior Authorization when required will result in the Member receiving a lesser or no Benefit. Please refer to thewww.ghcscw.com and your Member Certificate for a list of specific Benefits that require Prior Authorization.

If a Member fails to obtain written Prior Authorization for Covered Health Services from GHC-SCW, a Prior Authorization penalty shall apply (the “PriorAuthorization Penalty”). The Prior Authorization Penalty requires the Member to pay 50% of the Reasonable and Customary Fees and Charges billed toGHC-SCW for the Covered Health Service(s) that required Prior Authorization. The maximum Prior Authorization Penalty shall be $500. The PriorAuthorization Penalty shall be assessed prior to any applicable Deductible, Coinsurance and/or Copayment. The Prior Authorization Penalty does not applytoward the Member’s Maximum Out-of-Pocket. All Covered Health Services remain subject to the Member’s Deductible, Coinsurance and/or Copaymentfollowing assessment of the Prior Authorization Penalty. To obtain Prior Authorization, call (608) 257-5294.

Provider InformationFor Providers see the "Find a Provider" link at www.ghcscw.com or contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.In-Network Providers: For a list of In-Network Providers, see the "Find a Provider" link at www.ghcscw.com or contact Member Services at (608) 828-

4853 or (800) 605-4327, ext. 4504.Out-of-Network Providers: Out-of-Network Providers are any Providers not included in the “Find a Provider” link at www.ghcscw.com. Out-of-Network

coinsurance applies after the deductible has been met. For further assistance, contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.When applicable, Prior Authorization is still required for Out-of-Network services.

GHC-SCW Notices to MembersQualified Maximum Dependent Age: Dependents are covered until the end of the month at age 26.This is only a summary. You are responsible for knowing the full Benefits and provisions of your policy. Please read all documents carefully including

your Member Certificate, Formulary, Benefit Summary and Summary of Benefits and Coverage (SBC). To find these documents, visit www.ghcscw.com orcontact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.

Questions or Concerns?For any questions or concerns regarding your benefits, please visit www.ghcscw.com, or contact Member Services at (608) 828-4853 or (800) 605-4327,

ext. 4504.

$20 Copayment $100 Deductible 100/90 POS Plan

Plan Number: 1904720Benefits Accumulate on a Plan Year.

Policy CoinsuranceIn-Network: 0%Out-of-Network: 10%

MEMBER FAMILY

In-Network Deductible $100 $300Out-of-Network Deductible $200 $600

Medical In-Network Maximum Out-of-Pocket (MOOP) $200 $600Pharmacy In-Network Maximum Out-of-Pocket (MOOP) $2,000 $4,000

Out-of-Network Maximum Out-of-Pocket (MOOP) $400 $1,200

CSC16-25-01-1(06/16)C 2019 Benefit Summary (Page 3 of 3) POS-1904720-RSPri nte d: 6/6/2019 - 3:43 PM

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, please call 1-800-605-4327. For general definitions of commonterms, such as allowed amount, balance billing, coinsurance, copayment , deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at

www.healthcare.gov/sbc-glossary/ or call 1-800-605-4327 to request a copy. Important Questions Answers Why This Matters:

What is the overalldeductible?

For In-Network Providers $100/Individual or $300/Family;For Out-of-Network Providers $200/Individual or$600/Family

If you have other family members on the plan, each family member must meet their own individualdeductible until the total amount of deductible expenses paid by all family members meets the overall familydeductible.

Are there services coveredbefore you meet yourdeductible?

Yes. Complementary Medicine, Preventive Care, CertainOffice Visits, and Pharmacy Drugs are covered beforethe deductible is met. Office Visit Copayments arewaived for children under age 19.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copaymentor coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services athttps://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles forspecific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limitfor this plan?

Medical: For In-Network Providers $200/Individual or$600/Family; For Out-of-Network Providers$400/Individual or $1,200/FamilyPharmacy: For In-Network Providers $2,000/Individual or$4,000/Family; For Out-of-Network Providers No Out-of-Network Benefit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other familymembers on this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limithas been met.

What is not included in theout-of-pocket limit?

Copayments on certain services, premiums, balance-billingcharges, infertility services, and health care this plandoesn’t cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Will you pay less if you use anetwork provider?

Yes. See www.ghcscw.com or call 1-800-605-4327 for alist of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay themost if you use an out-of-network provider, and you might receive a bill from a provider for the differencebetween the provider's charge and what your plan pays (balance-billing). Be aware your network provider mightuse an out-of-network provider for some services (such as lab work). Check with your provider before you getservices.

Do you need a referral to seea specialist?

Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referralbefore you see the specialist.

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS1 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.comOMB Control Numbers 1545-2229, 1210-0147, and 0938-1146; Released on April 6, 2016

Common Medical Event Services You May Need

What You Will Pay

Limitations, Exceptions, Other ImportantInformation

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

If you visit a health care provider’s officeor clinic

Primary care visit to treat an injury or illness $20 10% after Deductible Example: Office visits with Your PrimaryCare Provider (PCP)

Specialist visit $20 10% after Deductible Prior authorization is required. Example:Autism Spectrum Specialist Office Visit

Preventive care/screening/immunization No Charge 10% after Deductible Coverage is limited to USPSTF guidelinesand Women's Preventive Health

If you have a test Diagnostic test (x-ray, blood work) No Charge after Deductible No Charge after Deductible Prior authorization is required. Examples:Lab tests, blood work, or x-rays ordered byYour Provider; Prior Authorization is notrequired when routine labs and x-rays areperformed at Your Primary Care Provider'sclinic

Imaging (CT/PET scans, MRIs) No Charge after Deductible No Charge after Deductible Prior authorization is required. Examples:CT, PET Scans, MRIs

If you need drugs to treat your illness orconditionMore information about prescription drugcoverage is available athttp://planfinder.ghcscw.com/

Generic drugs(Tier 1)

$0 Not Covered Covers up to a 30-day supply; 31-90 daysupply available for multiple Copays -subject to a maximum cost limit

Preferred brand drugs(Tier 2)

$5 Not Covered Covers up to a 30-day supply; 31-90 daysupply available for multiple Copays -subject to a maximum cost limit

Non-preferred brand drugs(Tier 3)

50% Copayment ($75 min/$150max)

Not Covered Covers up to a 30-day supply; 31-90 daysupply not available

Specialty drugs(Tier 4)

50% Copayment ($75 min/$150max)

Not Covered Covers up to a 30-day supply; 31-90 daysupply not available

If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge after Deductible 10% after Deductible Prior authorization is required.

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS2 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.com

Physician/surgeon fees No Charge after Deductible 10% after Deductible Prior authorization is required. Certain oralsurgeries do not require Prior Authorization

If you need immediate medical attention Emergency room care $100 $100 Coverage is limited to emergency care;Copayment waived if admitted as a hospitalinpatient

Emergency medical transportation No Charge after Deductible No Charge after Deductible Coverage is limited to emergency care

Urgent care $20 $20

If you have a hospital stay Facility fee (e.g., hospital room) No Charge after Deductible 10% after Deductible Prior authorization is required.

Physician/surgeon fees No Charge after Deductible 10% after Deductible Prior authorization is required.

If you need mental health, behavioralhealth, or substance abuse services

Outpatient services $20 10% after Deductible Prior authorization is required. PriorAuthorization is not required when servicesare provided at a GHC-SCW Clinic or at UWHealth Behavioral Health and RecoveryClinic

Inpatient services No Charge after Deductible 10% after Deductible Prior authorization is required.

If you are pregnant Office visits No Charge 10% after Deductible Coverage is limited to USPSTF guidelinesand Women's Preventive Health

Childbirth/delivery professional services No Charge after Deductible 10% after Deductible Prior authorization is required.

Childbirth/delivery facility services No Charge after Deductible 10% after Deductible Prior authorization is required.

If you need help recovering or haveother special health needs

Home health care No Charge after Deductible 10% after Deductible Prior authorization is required. Limited to 60visits per Member per year

Common Medical Event Services You May Need

What You Will Pay

Limitations, Exceptions, Other ImportantInformation

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS3 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.com

Rehabilitation services No Charge after Deductible 10% after Deductible Prior authorization is required. Limited to 40combined visits per Member per year forOccupational and Physical; Limited to 20visits per Member per year for Speech;Limited to 36 visits per Member per year forCardiac

Habilitation services Not Covered Not Covered Not Covered

Skilled nursing care No Charge after Deductible 10% after Deductible Prior authorization is required. Limited to 100Skilled Days per Member per year

Durable medical equipment 20% Not Covered Prior authorization is required. SeeCertificate for additional Limitations andExclusions

Hospice services No Charge after Deductible 10% after Deductible Prior authorization is required. Example: Endof Life Services

If your child needs dental or eye care Children’s eye exam No Charge Not Covered Vision examinations must be provided by anIn-Network Provider; Limited to one eyeexam per Member per year

Children’s glasses Not Covered Not Covered Not Covered

Children’s dental check-up Not Covered Not Covered Not Covered

Common Medical Event Services You May Need

What You Will Pay

Limitations, Exceptions, Other ImportantInformation

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS4 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.com

Excluded Services and Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: GHC-SCW Member Servicesat 1-800-605-4327 or Wisconsin’s Office of the Commissioner of Insurance at 1-800- 236-8517 or 608-266-0103. Other coverage options may be available to you too, including buying individualinsurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For moreinformation about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievancefor any reason to your plan. For more information about your rights, this notice, or assistance, contact: GHC-SCW Member Services at 1-800-605-4327 or 608-828-4853. You may also contactWisconsin’s Office of the Commissioner of Insurance at 1-800- 236-8517 or 608-266-0103. In addition, you may also contact the Department of Labor’s Employee Benefits Security Administrationat 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have healthcoverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Abortion (except in cases of rape, incest, or when the life ofthe mother is endangered)

Bariatric surgery Cosmetic surgeryCustodial Care Dental Care (Adult)

Drug Screening Long-term care Non-emergency care when traveling outside the U.S.Personal Comfort Items Private-Duty Nursing Routine Foot CareWeight Loss programs

Acupuncture Chiropractic Care Hearing AidsInfertility Treament (specific procedures and services at In-

Network facilities only)Routine Eye Care (Adult)

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS5 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.com

------------------------------------------- To see examples of how this plan might cover costs for a sample medical situation, see the next section. -------------------------------------------

About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual careyou receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded servicesunder the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only

coverage.

DeductiblesCopaymentsCoinsurance

Peg is having a baby(9 months of in-network pre-natal care and a hospital delivery)

The plan’s overall deductible -- $100Specialist -- $20Hospital (facility) -- No Charge after DeductibleOther -- 0%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost -- $12,800.00In this example, Peg would pay:

Cost sharing$100.00$0$0

What isn't coveredLimits or exclusions -- $10.00The total Peg would pay is -- $110.00

DeductiblesCopaymentsCoinsurance

Managing Joe's type 2 Diabetes(a year of routine in-network care of a well-controlled condition)

The plan’s overall deductible -- $100Specialist -- $20Hospital (facility) -- No Charge after DeductibleOther -- 0%

This EXAMPLE event includes services like:Primary care physician office visits (including diseaseeducation)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)Total Example Cost -- $7,400.00In this example, Joe would pay:

Cost sharing$60.00$120.00$120.00

What isn't coveredLimits or exclusions -- $20.00The total Joe would pay is -- $320.00

DeductiblesCopaymentsCoinsurance

Mia’s Simple Fracture(in-network emergency room visit and follow up care)The plan’s overall deductible -- $100Specialist -- $20Hospital (facility) -- No Charge after DeductibleOther -- 0%

This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost -- $1,930.00In this example, Mia would pay

Cost sharing$100.00$100.00$0

What isn't coveredLimits or exclusions -- $0The total Mia would pay is -- $200.00

Coverage Period: 7/1/2019 - 6/30/2020Coverage for: Member | Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

$20 Copayment $100 Deductible 100/90 POS Plan

POS-1904720-RS6 of 6Printed: 6/6/2019 - 3:43 PM

*For more information about limitations and exceptions, see the plan or policy document at http://planfinder.ghcscw.com

CSC18-29-01-1(07/18)F Version 2: 7/2018

GHC-SCW Nondiscrimination Notice

Group Health Cooperative of South Central Wisconsin (GHC-SCW) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GHC-SCW does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

GHC-SCW: • Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504 (TTY: 1- 608-828-4815).

If you believe that GHC-SCW has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with GHC-SCW’s Corporate Compliance Officer, 1265 John Q. Hammons Drive, Madison, WI 53717, Telephone: (608) 251-4156, TTY: (608) 828-4815, or Fax: (608) 257-3842. If you need help filing a grievance, GHC-SCW’s Corporate Compliance Officer is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509f, HHH Building Washington, DC 20201 1-800-368-1019, 1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

GHC-SCW Language Assistance Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Hmoob (Hmong): LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-608-828-4853 or 1- 800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815)。

CSC18-29-01-1(07/18)F Version 2: 7/2018

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

:(Arabic) العربیة رقم( ext. 4504 ,4327-605-800-1 ,4853-828-608-1 برقم اتصلاللغویة تتوافر لك بالمجان. ملحوظة: إذا كنت تتحدث العربیة، فإن خدمات المساعدة

4815-828-608-1) والبكم الصم ھاتف

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815) 번으로 전화해 주십시오.

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Deitsch (Pennsylvania Dutch): Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Français (French): ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

�हदं� (Hindi):

ध्यान द�: य�द आप �हदं� बोलत ेह� तो आपके �लए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1-608-828-4853 or 1-800-605-

4327, ext. 4504 (TTY: 1-608-828-4815) पर कॉल कर�।

Shqip (Albanian): KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

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Notice of Privacy PracticesEFFECTIVE DATE OF THIS NOTICE: 9/23/13

EFFECTIVE DATE OF THIS NOTICE: 12/14/12EFFECTIVE DATE OF THIS NOTICE: 1/1/10EFFECTIVE DATE OF THIS NOTICE: 12/1/08

ORIGINAL EFFECTIVE DATE: 04/14/03

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.

INTRODUCTION TO THE GHC-SCW NOTICE OF PRIVACY PRACTICES

Each time you visit Group Health Cooperative of South Central Wisconsin (GHC-SCW) for health care, it is documented in your electronic medical record. This record contains identification and financial information as well as symptoms, diagnoses, test results, a description of your physical examination, and a treatment plan. This record is often referred to as your “medical record” or “health information.” GHC-SCW may also store your information on paper. Your health information is used to: (1) plan for your care and treatment; (2) for communication among your health care professionals; (3) as a legal document describing the care you received; (4) as a way for you or your insurance company to verify the services provided; (5) to help GHC-SCW review and improve health care and outcomes; and (6) for other similar activities that allow GHC-SCW to conduct business efficiently and provide you with high quality health care.

This Notice provides you with the following important information: How we use and disclose your protected health information Your privacy rights with regard to your protected health information Our obligations to you concerning the use and disclosure of your protected health information

The terms of this Notice apply to all designated GHC-SCW records containing your protected health information (PHI) that are created and maintained by our organization. We reserve the right to revise or amend our Notice of Privacy Practices (Notice). Any revisions or amendments to the Notice will be effective for all of your records created or maintained in the past as well as any records we create or maintain in the future. We will post a copy of the most current Notice in a prominent location at each of our sites. We will also post the most current Notice to our organizational website. GHC-SCW will abide by the terms of the Notice currently in effect. At any time, you may request a copy of our most current Notice. You may acknowledge receipt of this Notice.

GHC-SCW HEALTH CARE PROVIDERS’ DUTY TO PROTECT YOUR HEALTH INFORMATION

Under the Health Insurance Portability and Accountability Act of 1996 (a federal law also known as “HIPAA”), GHC-SCW providers are required to keep your health information confidential, and to provide you with this Notice. This Notice describes how GHC-SCW providers use and disclose your health information. GHC-SCW providers consist of several different types of health care professionals including physicians, physician assistant’s, nurse practitioners, nurses, lab technicians and other clinical and administrative staff. Your health information may also be provided to health care professionals contracted with GHC-SCW, such as UWHC specialists and other health care organizations, involved in your care and treatment. GHC-SCW stores your information primarily in an electronic format that is protected by stringent privacy and security mechanisms. Providers collect, create, maintain, use and disclose your health information.

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GHC-SCW PRIVACY PRACTICES

GHC-SCW provides care and administers health insurance benefits to our members in partnership with physicians and other professionals and organizations. Our privacy practices are observed by:

Any of our health care professionals who care for you at any one of our locations or sites; All locations and departments that are part of our organization; and All members of our workforce to include employees, students, contractors, interpreters and interns.

SHARED MEDICAL RECORD

We participate in a regional arrangement of health care organizations, who have agreed to work with each other, to facilitate access to health information that may be relevant to your care. For example, if you are admitted to a hospital on an emergency basis and cannot provide important information about your health condition, this regional arrangement will allow us to make your health information from other participants available to those who need it to treat you at the hospital. When it is needed, ready access to your health information means better care for you. We store health information about our patients in a joint electronic medical record with other health care providers who participate in this regional arrangement. You may contact GHC-SCW at (800) 605-4327, the Member Services Department, for a list of healthcare providers who participate in the joint electronic medical record.

HOW GHC-SCW WILL USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

We are committed to ensuring that your health information is used responsibly by our organization. We collect health information about you and store it in electronic files. We may use and disclose health care information for the following purposes:

1. Treatment. We may use or disclose your health information for treatment purposes without yourauthorization. In the course of treatment, we may find it necessary to share your health information withphysicians, physician assistants, nurse practitioners, nurses, lab, radiology and others involved in your careand treatment such as a hospital where you may be transferred.

2. Payment Functions to determine eligibility for health plan benefits, obtain premiums, facilitate paymentand services you receive from other health care providers, determine health plan responsibility for benefitsand to coordinate benefits your information may be used without your authorization. For example, paymentfunctions may include reviewing the medical necessity of health care services, determining whether aparticular treatment is experimental or investigational, or determining whether a treatment is covered underyour health plan.

3. Health Care Operations for health care operations such as to ensure health benefits are properlyadministered and to receive cost-effective, high quality health care your health information may be usedwithout your authorization. Activities may include evaluating the performance of your doctors, nurses andother health care professionals, or examining the effectiveness of treatment provided to you when comparedto patients in similar situations. Other activities include underwriting, premium rating, and other health planrating coverage, quality improvement activities, submitting claims for stop-loss coverage, conducting orarranging for medical review, legal services, audits and business planning.

4. Information Provided to You and for You. We may use your health information to assist us incommunicating with you about appointment reminders, test results and treatment information and healthcare options. Our communications to you may be made by phone, GHCMyChart, in person, by mail orother secure channels.

5. Appointment Reminders. We may contact you by phone for the purpose of appointment reminders orchanges, notification of events such as flu clinics, announcements and to communicate other information

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designed to provide you with high quality care and treatment. These contacts may be transmitted in an electronic format or an in-person telephone call, or through other channels of communication. GHC-SCW will leave messages on answering machines, voicemail, or when appropriate, another person who answers your telephone. If you have specific preferences (i.e. leave messages only on my cell phone) or if you would like to opt-out of telephone reminders, please contact the GHC-SCW Member Services Department at (608) 828-4853 or (800) 605-4327.

6. Required by Law. When required by state or federal law, with or without your authorization, GHC-SCWmust provide it. An example would be when a request is mandated by a court in a litigation proceeding.

7. Correctional Institutions. If you are an inmate of a correctional institution, we may disclose to theinstitution your health information necessary for your health and the health and safety of others.

8. Law Enforcement. To identify a suspect, fugitive, material witness or missing person, for compliance witha court order or subpoena or various other law enforcement activities.

9. Victims of Abuse, Neglect, or Violence. We may disclose your information to a governmental authorityauthorized by law to receive reports of abuse, neglect or violence relating to children or the elderly.

10. Public Health. As required by law, we may disclose your health information to public health authorities forpurposes related to: preventing or controlling disease, injury or disability; reporting child or elder abuse orneglect; reporting domestic violence; reporting to the Food and Drug Administration (FDA) to othergovernment agency problems with products and reactions to medications; and reporting disease orinfectious exposure.

11. Health Oversight Activities. To health oversight agencies during the course of audits, investigations,inspections, licensure, certifications and other proceedings.

12. Judicial and Administrative Proceedings. In the course of any administrative or judicial proceeding.13. Coroners or Medical Examiners: We may disclose your information to coroners or medical examiners

and funeral directors. We may disclose this information to assist in the identification of and/or investigationof deceased person or determine a cause of death.

14. Organ and Tissue Donation. To organizations involved in procuring, banking or transplanting organs andtissues.

15. Public Safety. To prevent or lessen a serious and imminent threat to the health and safety of a particularperson or the general public.

16. National Security. For military, national security, prisoner and government benefit purposes.17. Worker’s Compensation. To comply with Worker’s Compensation or similar laws.18. Plan Sponsor Disclosures. Information about your enrollment or disenrollment to the sponsor of your

group health plan for the purpose of administering benefits.19. Research. To conduct research. Such use or disclosure occurs only under certain circumstances and with

specific approval.20. Health Information Marketing. We may use your health information to give you information about other

treatments or health-related benefits and services that we provide and that may be of interest to you. If youdo not want GHC-SCW to use your information for such purposes, you may notify us at (800) 605-4327,extension 4237, the GHC-SCW Privacy Officer.

21. Health Information Availability After Death. GHC-SCW may use or disclose your protected healthinformation without your authorization 50 years after the date of your death. If you wish to restrict such useand disclosure, see “Request Restrictions” below.

22. To Those Involved With Your Care or Payment. To a family member, relative or other personspecifically identified by you in advance of such a disclosure. GHC-SCW requires most adult patients tocomplete and submit an Authorization to Disclose Protected Health Information Form in advancespecifically providing your written permission for GHC-SCW to interact with this other individual (i.e. ifyou want GHC-SCW to communicate freely with your spouse or others about any aspect of your health careand treatment). If you are given an opportunity to object to this disclosure and you do express this

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objection, or if circumstances reasonably infer, GHC-SCW providers will use professional judgment to determine how an interaction should be handled. If you are not present or the opportunity to agree or object cannot practicably be provided due to incapacity or emergency circumstances, GHC-SCW will determine whether the disclosure of relevant information is in your best interest. We may disclose information about you to an entity assisting in disaster relief efforts so that your family can be notified about your condition, status and location.

*The Genetic Information Nondiscrimination Act of 2008 (GINA), prohibits discrimination based on a person’sgenetic information related to health coverage and employment. Section 105 contains a provision entitled “Privacy and Confidentiality” that the Department of Human Services (DHS) is using to propose modifications that would: clearly state that “genetic information is health information;” prohibit the use or disclosure of PHI that is genetic information by health plans for underwriting purposes; amend the Notice of Privacy Practices for health plans performing underwriting; make modifications to definitions and update the definition of “health plan.” For more information, go to http://edocket.access.gpo.gov/2009/E9-22492.htm.

WHEN GHC-SCW IS REQUIRED TO OBTAIN AN AUTHORIZATION TO USE OR DISCLOSE YOUR HEALTH INFORMATION

Except as described in this Notice of Privacy Practices, GHC-SCW will not use or disclose your protected health information without your written authorization. For example, uses and disclosures made for the purpose of psychotherapy, marketing and sale of protected health information require your authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. GHC-SCW does not disclose individual specific health care information to plan sponsors. It is also your right to revoke a previously-submitted authorization. This revocation must be submitted in writing and GHC-SCW will not apply to information already disclosed.

STATEMENT OF YOUR HEALTH INFORMATION RIGHTS

You Have the Right To:

1. Inspect and Copy Your Health Information. You have the right to inspect and obtain a copy ofyour health care information. You have the right to request that the copy be provided in anelectronic format (e.g., PDF saved onto a DVD). If the form and format are not readily producible,then GHC-SCW will work with you to provide it in a reasonable electronic form or format. Thisdoes not apply to psychotherapy notes, which are maintained for the personal use of a mental healthprofessional.

2. Request Restrictions. You have the right to request restrictions on how your health information isused or to whom your information is disclosed, even if that restriction affects your treatment orpayment or health care operations. We are not required to agree in all circumstances to yourrequested restrictions, except in cases of a disclosure restricted to a health plan if the disclosure is forthe purpose of carrying out treatment or health care operations and is not otherwise required by law;and the PHI pertains solely to a health care item or service for which you, or the person other thanthe health plan on your behalf, has paid the covered entity in full. If you would like to make arequest for restrictions, you must submit your request in writing to the GHC-SCW Privacy Officer at(608) 662-4899.

3. Request Confidential Communications. To ask that we communicate your protected healthinformation to you in different ways or places. For example, you may wish to receive informationabout your health status at work, rather than home. To request confidential communications, youmust submit your request in writing to the GHC-SCW Privacy Officer at (608) 662-4899.

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4. Request Record Amendment. If you believe that your protected health information is incorrect orincomplete, you must submit a written request to have it amended. Upon receipt of the request,GHC-SCW may approve or deny your request. You will be informed of our decision and given theright to appeal this decision.

5. Accounting of Disclosures. To ask for a list of the disclosures of your protected health informationGHC-SCW has made during the previous six years, not to include dates prior to 4/14/03. We willcomply with your request within 30 days unless you agree to a 30-day extension. We will notinclude in the list any disclosures made to you or for the purpose of treatment, payment or healthcare operations, limited data sets, national security, law enforcement or corrections and certainhealth oversight activities.

6. Notification of a Breach. GHC-SCW is required by law to maintain the privacy of protected healthinformation and provide you with a notice of its legal duties and privacy practices with respect toprotected health information and to notify you following a breach of unsecured protected healthinformation.

7. Receive a Copy of the Notice of Privacy Practices. You will receive a copy of this Notice in yourMembership Information Booklet upon enrollment. The document is also available in the followingways:a. Obtain from the Notice of Privacy Practices kiosk in the designated area at the entrance to your

clinic.b. Contact the Privacy Officer at (608) 662-4899.c. Go to our Web site at www.ghcscw.com.

CHANGES TO THE NOTICE OF PRIVACY PRACTICES

GHC-SCW may change this Notice of Privacy Practices and notify you if we make any material changes. Until such time, GHC-SCW is required by law to comply with the current version of this Notice.

COMPLAINTS ABOUT GHC-SCW PRIVACY PRACTICES

Complaints about this Notice or about how we use or disclose your protected health information should be directed to the Privacy Officer at (608) 662-4899. It is your right to file a complaint with GHC-SCW and doing so will not affect your care and treatment, nor will we retaliate against any person for filing a complaint. You also have the right to file a complaint with the Office of Civil Rights at http://www.hhs.gov/ocr/hipaa/.

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

At GHC-SCW, the privacy of your protected health information is important to us. In this mailing, we have provided you with the Notice of Privacy Practices. It describes your privacy rights and GHC-SCW’s responsibilities. We ask that you sign and return this acknowledgement form to confirm that you have received the Notice of Privacy Practices. However, it is your choice whether or not to sign and return the form, it is optional and choosing not to do so will not affect your care and treatment in any manner.

I have received the GHC-SCW Notice of Privacy Practices.

________________________________________ __________________________Patient Name GHC member or group number

_________________________________________ __________________________Signature of Patient or Personal Representative Date of Signature

Frequently Asked Questions About the Acknowledgement of Receipt of Notice of Privacy Practices

Q: Why are you giving me this Notice?A: For two reasons: (1) we feel that it is

important that you understand how we use your health information; and (2) HIPAA, a federal law, requires that we provide this information to you.

Q: Do I have to read this?A: No, it is your choice. You can keep for your

personal files or discard as you wish.

Q: I don’t like to sign things. Do I have to sign it?

A: No, it is your choice. Choosing not to do so will not affect your care and treatment in any manner.

Q: What if I refuse to sign?A: If you choose not to sign, it will have no

impact on the care or service that you receive at GHC-SCW.

Q: It seems like I just signed one of these. Do I have to sign it again?

A: No.

Questions? Contact the Privacy Officer at (608) 662-4899.

Q: Does every member of my family have to sign?

A: If you choose to sign, each adult should sign for themselves. The parent or legal guardian should sign for a separate form for each minor child under the age of 18 (each of you should have been mailed their own form).

Remember, we have to offer that you sign the form, but you do not need to accept.

Q: Can I sign for my spouse, adult child or elderly family member?

A: It is preferred that each adult sign for him/herself unless it is impossible for an individual to sign for themselves.

Send, fax or e-mail completed form to:

GHC-SCW Privacy Officer, 1265 John Q. Hammons Drive, Madison, WI 53717ORFax to (608) 662-4965ORE-mail as PDF attachment to jcoleman@ghcscw.com

Please clip and keep as a quick reference.

Group Health Cooperative of South Central Wisconsin (GHC-SCW)

Primary Care Clinics

GHC-SCW ClinicsCapitol Clinic (608) 257-9700 675 W. Washington Ave., Madison, WI 53703 Wed, Fri: 8 a.m. – 5 p.m. Mon, Tues, Thurs: 8 a.m. – 7 p.m.

DeForest Clinic (608) 846-4787 815 S. Main St., DeForest, WI 53532 Mon – Fri: 8 a.m. – 4:30 p.m.

East Clinic (608) 222-9777 5249 E. Terrace Dr., Madison, WI 53718 Mon: 8 a.m. – 7 p.m. Tues – Fri: 8 a.m. – 5 p.m.

Hatchery Hill Clinic (608) 661-7200 3051 Cahill Main, Fitchburg, WI 53711 Mon, Wed – Fri: 8 a.m. – 5 p.m. Tues: 8 a.m. – 7 p.m.

Madison College Community Clinic (608) 441-3220 Health Education Center-Truax Campus 1705 Hoffman St., Madison, WI 53704 Mon: 7 a.m. – 7 p.m. Tue – Fri: 7 a.m. – 5 p.m.

Sauk Trails Clinic (608) 831-1766 8202 Excelsior Dr., Madison, WI 53717 Mon: 8 a.m. – 7 p.m. Tues – Fri: 8 a.m. – 5 p.m.

UW Health Family Medicine ClinicsBelleville Family Medicine Clinic (608) 424-3384 1121 BellWest Blvd., Belleville, WI 53508 Mon – Fri: 8 a.m. – 5 p.m.

Northeast Family Medical Center (608) 241-9020 3209 Dryden Dr., Madison, WI 53704 Mon – Fri: 8 a.m. – 5 p.m.

Verona Clinic (608) 845-9531 100 N. Nine Mound Rd. Verona, WI 53593 Mon – Fri: 8 a.m. – 5 p.m.

UW Health ClinicsCottage Grove Clinic (608) 839-3104 4590 Hwy N, Cottage Grove, WI 53527 Mon – Fri: 8 a.m. – 5 p.m.

Cross Plains Clinic (608) 798-3344 2418 Brewery Rd., Cross Plains, WI 53528 Mon – Fri: 8 a.m. – 5 p.m.

Mt. Horeb Clinic (608) 437-3064 600 N. 8th St., Mt. Horeb, WI 53572 Mon – Fri: 8 a.m. – 5 p.m.

UW Health - Stoughton ClinicStoughton Clinic (608) 877-2660 1001 Nygaard St., Stoughton, WI 53589 Mon – Fri: 8 a.m. – 5 p.m

Access Community Health CentersJoyce and Marshall Erdman Clinic (608) 443-5480 2202 S. Park St., Madison, WI 53713 Mon – Fri: 7 a.m. – 5 p.m.

William T. Evjue Clinic (608) 443-5480 3434 E. Washington Ave. Madison, WI 53704 Mon – Fri: 8 a.m. – 5 p.m.

Wingra Family Medical Center (608) 263-3111 1102 S. Park St., Madison, WI 53715 Mon – Fri: 8 a.m. – 5 p.m.

virtuwell®

virtuwell® is your 24/7 online clinic for a diagnosis, treatment plan and even a prescription for common medical conditions. Get better faster.

Visit ghcscw.com/virtuwell

GHC NurseConnect

GHC NurseConnect is your 24-hour nurse advice line when you need general care advice over the phone. Get the information you need when you need it.

Call (608) 661-7350 or toll-free (855) 661-7350

ghcscw.com

GHC-SCW Urgent CareAnytime you need medical care (except for emergencies), you should first call your primary care clinic for an available appointment. If you need medical care after normal primary care clinic hours, call the GHC-SCW urgent care clinic to schedule an appointment:

(608) 442-8100675 W. Washington Ave., Madison, WI 53703

Mon – Fri: 8 a.m. – 9 p.m. Sat – Sun: 9 a.m. – 9 p.m.

We schedule urgent care appointments to better serve your same-day access needs.

MK18-85-0(8.18)O

1265 John Q Hammons Dr. Madison, WI 53717-1962

ghcscw.com