Paramount Insurance Company Large Group Ohio Commercial HMO Member Handbook

Transcription

1 Paramout Isurace Compay Large Group Ohio Commercial HMO Member Hadbook Paramout is the health isurace optio that offers a diverse lie of products, a broad provider etwork, high quality ad local, depedable service.

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3 Paramout Isurace Compay Large Group Ohio Commercial HMO Member Hadbook Provided by:

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5 HMO Member Hadbook NOTICE CONCERNING COORDINATION OF BENEFITS (COB) IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY CAREFULLY, INCLUDING THE COORDINATION OF BENEFITS SECTION, AND COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU OR YOUR FAMILY. Gradfathered Health Pla Paramout believes this pla is a gradfathered health pla uder the PPACA. As permitted by PPACA, a gradfathered health pla ca preserve certai basic health coverage that was already i effect whe the law was eacted. Beig a gradfathered health pla meas that your pla may ot iclude certai cosumer protectios of PPACA that apply to other plas, for example, the requiremet for the provisio of prevetive health services without ay cost sharig. However, gradfathered health pla must comply with certai other cosumer protectios i PPACA, for example, the elimiatio of lifetime limits o beefits. Questios regardig which protectios apply ad which protectios do ot apply to a gradfathered health pla ad what might cause a pla to chage from gradfathered health pla status ca be directed to Paramout Isurace Compay at (419) ; toll-free You may also cotact the Employee Beefits Security Admiistratio, U.S. Departmet of Labor at or This website has a table summarizig which protectios do ad do ot apply to gradfathered health plas. 1

6 HMO Member Hadbook I Case of Emergecy Call 911, a ambulace or rescue squad or go directly to the earest emergecy facility. A Emergecy Medical Coditio meas a medical coditio that maifests itself by such acute symptoms of sufficiet severity, icludig severe pai that a prudet layperso with a average kowledge of health ad medicie could reasoably expect the absece of immediate medical attetio to result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma or the ubor Child, i serious jeopardy; b) Serious impairmet to bodily fuctios; or c) Serious dysfuctio of ay bodily orga or part. Your Primary Care Provider ca be reached 24 hours a day, seve (7) days a week. If you eed medical advice after hours, o weekeds or holidays, call your doctor s office umber. The aswerig service will take your call. Leave a message for the doctor or a urse to retur your call. A doctor or urse will call you back with istructios. List the ames ad umbers of the Primary Care Provider for each family member. Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Police Rescue Hospital Other Fire Ambulace Poiso Cotrol 2

7 HMO Member Hadbook Dear Member: Welcome to Paramout Isurace Compay. This hadbook will help you uderstad ad use your beefits most effectively. The Primary Care Provider you chose whe you joied will help you whe you eed medical care. ALWAYS CONTACT YOUR PRIMARY CARE PROVIDER FIRST uless there is a Emergecy Medical Coditio. He or she will help you coordiate all your medical care. If you did ot eed to chage doctors, be sure to call your Primary Care Provider s office as soo as possible to let them kow you are ow covered by Paramout Isurace Compay. If you did chage doctors, it is a good idea to get to kow your doctor so you ca feel comfortable askig questios, especially if a Emergecy Medical Coditio arises. If you are a ew patiet with your Primary Care Provider, we ecourage you to call the doctor s office for a appoitmet as soo as you ca to discuss your medical history ad get to kow each other. This Member Hadbook also explais who is covered uder your pla ad how the Pla works. Please take a few miutes to read it. If you have ay questios or eed help uderstadig your beefits, please call Member Services, Moday through Friday, 8:00 a.m. to 5:00 p.m. We look forward to servig you. The Member Services Departmet The official terms of your erollmet ad health beefits through Paramout Isurace Compay are stated i the Group Medical ad Hospital Service Agreemet (GSA) ad all applicable Documets as defied i paragraph of the GSA, all of which are o file with your employer. This Member Hadbook cotais a summary of your rights ad obligatios regardig your erollmet ad health beefits through Paramout Isurace Compay. If there are ay icosistecies betwee this Member Hadbook ad the Group Medical ad Hospital Service Agreemet, the Service Agreemet will cotrol. 3

8 HMO Member Hadbook Paramout Isurace Compay is a affiliate of ProMedica a locally owed, oprofit healthcare orgaizatio servig orthwest Ohio ad southeast Michiga. 4

9 Table of Cotets Table of Cotets 1. The Basics...7 How Paramout Works...7 Your Idetificatio Card...7 Is There a Pre-existig Coditio Restrictio?...8 What Are Deductibles?...8 What are Copaymets ad Coisurace?...8 Who to Call for Iformatio...9 Members Rights...9 Members Resposibilities Gettig a Doctor s Care...10 Start with Your Primary Care Provider...10 Whe You Need OB/GYN Care...12 Utilizatio Maagemet...13 Eterig the Hospital...14 Chage i Beefits...14 If a Provider Leaves the Pla...14 If a Specialist Leaves the Pla...15 Cotiuity of Treatmet...15 Provider Reimbursemet / Filig a Claim...15 No-Covered Services...15 If You Receive a Bill...15 New Techology Assessmet...16 Privacy ad Cofidetiality...16 Owership ad Physicia Compesatio...16 Patiet Safety What to Do for Urget Care or Emergecy Medical Coditios...18 Urget Care Services...18 Emergecy Services...19 The Paramout Service Area Your Pla...20 What Is Covered - I Geeral...20 What Is Not Covered - I Geeral...21 What Is Covered/What Is Not Covered - Specific Services...21 Who Is Eligible...32 Addig ad Removig Members...34 Reewal of Coverage...35 Termiatio of Member Coverage...35 Beefits After Cacellatio of Coverage

10 Table of Cotets 5. What Happes with Your Pla...36 Whe You Have Other Coverage How Coordiatio of Beefits Works...36 Whe You Are Eligible for Medicare...41 Whe You Qualify for Worker s Compesatio...41 Whe Someoe Else Is Liable (Subrogatio ad Reimbursemet)...41 Whe You Leave Your Job...41 How You May Cotiue Group Coverage Iteral Claims ad Appeals Procedures ad Exteral Review Terms ad Defiitios...50 Schedule of Beefits...Isert 6

11 HMO Member Hadbook 1. THE BASICS How Paramout Works Your Primary Care Provider is your first cotact whe you eed medical care. Your PCP will coordiate your medical care with other Participatig Providers i the Paramout etwork. Female Members may receive OB/GYN care from a participatig obstetrics/gyecology specialist without Prior Authorizatio from the Primary Care Provider (PCP). For childre, you may desigate a pediatricia as the PCP. Prior Authorizatio is required for certai procedures or services. It is the resposibility of the Participatig Provider to obtai Prior Authorizatio from Paramout i advace of these procedures or services. Your Idetificatio Card Member idetificatio umber Member s ame Your Persoal Physicia s ame ad phoe umber Your copay for PCP office visit MEMBER NAME JOHN DOE PRIMARY CARE PHYSICIAN JOHN PHYSICIAN PCP SPEC ER RX $X $X $XX ID NUMBER XXXXXXXXX XX GROUP NUMBER XXXXXXXXXX EFF. DATE XX/XX/XX Paramout Isurace Compay is icorporated i Ohio uder Paramout Care, Ic. EMERGENCY SERVICES I case of a emergecy medical coditio call 911 or go to the earest medical facility. I all other cases, cotact your PCP for istructios. SPECIALTY SERVICES Your Primary Care Provider is your first cotact for o-emergecy medical care ad will recommed a participatig specialist if additioal care is eeded. Go to for the most curret listig of participatig providers. HOSPITAL ADMISSIONS Prior authorizatio must be obtaied by the hospital prior to all o-emergecy admissios by callig Whe travelig out-of-area, call PHCS at for preferred providers. Member Services: , Optio 6 TTY: (419) OR Claims Address: P.O. Box 497, Toledo, OH Mailig Address: P.O. Box 928 Toledo, OH Ask Paramout Nurse Lie: Copay for specialist visit Copay for covered emergecy room treatmet Idicates prescriptio drug coverage Member Services phoe umbers for questios ad complaits 7

12 HMO Member Hadbook Every Paramout Member receives a Paramout idetificatio card with his or her ame. The ame of that perso s Primary Care Provider (PCP) is o the card. If your card is lost or stole or ay iformatio is icorrect, call Member Services immediately. A ew card will be mailed to you promptly. Please check to see that the iformatio prited o the frot of your I.D. card is correct. If there are ay errors call: Member Services Departmet (419) Toll-Free TTY (419) TTY Toll-Free Be sure to familiarize yourself ad your family with the istructios o the back of the card. Is There a Pre-existig Coditio Restrictio? Paramout Isurace Compay does ot have ay restrictios o pre-existig coditios. I other words, if you were beig treated for a coditio before you became a Paramout member, Paramout will provide beefits for Covered Services related to that coditio o or after your effective date with Paramout as log as you follow the procedures described i Sectio 2, Gettig a Doctor s Care. What Are Deductibles? A Deductible is the amout you must pay for Covered Services withi each Cotract Year before beefits will be paid by Paramout. A Deductible caot exceed $1,000 per sigle or $2,000 per family per Cotract Year. If your pla has a Deductible, it will be stated i your Schedule of Beefits. The sigle Deductible is the amout each Member must pay, ad the family Deductible is the total amout ay two or more covered family members must pay Prevetive Health Services/ Beefits ad Covered Services requirig a Copaymet are ot subject to the Deductible. See Sectio 4, Your Pla for a list of Prevetive Health Services/ Beefits. What Are Copaymets ad Coisurace? Paramout members pay Copaymets (copays) or Coisurace for Basic Health Services such as: office visits ad services, ipatiet services (services you receive while a patiet i a hospital or other medical facility), outpatiet medical services, emergecy services, laboratory ad radiology services, services for treatmet of Biologically ad No-Biologically Based Metal Illess ad substace abuse ad prevetive health services. There are o lifetime beefit limits o Basic Health Care Services. Copaymets or Coisurace for a Basic Health Service will ot exceed 40% of the average cost to Paramout of providig the service. See your Schedule of Beefits for Copaymets/Coisurace o specific services. Copaymets are payable at the time you receive services. The Out-of-Pocket Copaymet Limit is the maximum amout of Copaymets ad Coisurace icludig the Deductible you pay every Cotract Year. Oce the Out-of-Pocket Copaymet Limit is met, there will be o additioal Copaymets ad Coisurace o Basic Health Services durig the remaider of the Cotract Year. The Out-of-Pocket Copaymet Limit is stated i your Schedule of Beefits. The sigle Out-of-Pocket Copaymet Limit is the amout each Member must pay, ad the family Out-of-Pocket Copaymet Limit is the total amout ay two or more covered 8

13 HMO Member Hadbook family members must pay. This Out-of-Pocket limit caot exceed 200% of the average aual premium to Subscribers ad Members. Copaymets ad Coisurace for Supplemetal Health Services such as; home health care, durable medical equipmet, prosthetic devices, outpatiet physical, occupatioal ad speech therapy, visio care services or prescriptio drugs ad ay pealties do ot cout toward the Out-of-Pocket Copaymet Limit. Who to Call for Iformatio The Paramout Member Services Departmet is here to help you. Call, if you: Have ay questios about your coverage Have questios about the providers who participate with Paramout Have questios about how to obtai health care services Need help uderstadig how to use your beefits Need to chage your Primary Care Provider Are chagig addresses, or eed to add a ew family member to your pla Lose your Paramout idetificatio card Or have ay other health care coverage cocers MEMBERS RIGHTS As a Member of Paramout, you have certai rights that you ca expect from Paramout ad Paramout providers. You have the right to: Receive iformatio about Paramout, its services, providers ad your rights ad resposibilities. Participate with your physicias i decisio-makig regardig your health care. A cadid discussio of appropriate or medically ecessary treatmet optios for the coditios regardless of cost or beefit coverage. Be treated with respect, recogitio of your digity ad the eed for privacy. Make recommedatios regardig Paramout s Member rights ad resposibilities policies. Voice complaits or appeals about the health pla or care provided. MEMBERS RESPONSIBILITIES As a Member of Paramout, you have certai resposibilities that Paramout ad Paramout providers ca expect from you. You have the resposibility to: Provide, to the extet possible, iformatio that Paramout ad the Participatig Providers eed to care for you. Help your PCP fill out curret medical records by providig curret prescriptios ad your previous medical records. Egage i a healthy lifestyle, become ivolved i your health care ad follow the plas ad istructios for the care that you have agreed o with your PCP or specialists. Uderstad your health problems ad participate i developig mutually agreed-upo treatmet ad goals to the degree possible. 9

14 HMO Member Hadbook 2. GETTING A DOCTOR S CARE Start with Your Primary Care Provider (PCP) Your PCP is the doctor you chose to hadle your medical care through your Paramout pla. Paramout requires the desigatio of a Primary Care Provider (PCP) for each Member. You have the right to desigate ay PCP who participates i the Paramout etwork as a PCP ad who is available to accept you or your family members. PCPs are family practitioers, iterists ad pediatricias participatig i the Paramout etwork. For childre, you may desigate a pediatricia as the PCP. Each family member ca have a differet PCP. For iformatio o how to select a PCP, ad a list of the Participatig PCPs, cotact Paramout Member Services at (419) or toll-free A directory of Participatig Providers is also available at: If you have chose a doctor you have ot see before, make a appoitmet ad get to kow the doctor ad staff. The more comfortable you are with your doctor - ad the better your doctor kows you - the more effective your health care ca be. For doctor appoitmets, call your PCP s office. Paramout maitais specific access stadards to make sure you get the care you eed o a timely basis. Access refers to both telephoe access ad the ability to schedule appoitmets. If you are havig difficulty schedulig a appoitmet or reachig a provider s office, please cotact the Member Service Departmet. They will assist you. Please call as far i advace as possible for a appoitmet. Use the followig table of Access Stadards as a guide for the lead-time you should allow. ACCESS STANDARDS for MEDICAL HEALTH CARE SERVICES Type of Care Required Expected Access Stadards Routie assessmets, physicals or ew visits Routie follow-up visits (for recurrig problems related to chroic ailmets like high blood pressure, asthma, diabetes, etc.) 30 days 14 days Symptomatic, o urget symptoms (cold, sore throat, rash, muscle pai, headache) Urget medical problems (uexpected illesses or ijuries requirig prompt attetio soo after they appear; urget care problems are ot permaetly disablig or life-threateig; a example would be a persistet high fever) Emergecy Medical Coditios (such as heart attack, stroke, poisoig, loss of cosciousess, iability to breathe, ucotrolled bleedig ad covulsios) 2-4 days 1-2 days Immediately call 911 or seek medical treatmet. Afterward, call your PCP for follow-up care. 10

15 HMO Member Hadbook ACCESS STANDARDS for BEHAVIORAL HEALTH CARE SERVICES Type of Care Required Emergecy Care, immediate threat to self or others (acutely suicidal or homicidal) Urget Care, may ot be life-threateig, but requires urget attetio (complex or dual problems) Routie Care/ Office Visit for ew problems upo request of the member or provider Routie Care/ Office Follow-Up Visits Immediately call 911 or seek medical treatmet. The call your PCP for follow-up care 1-2 days 14 days 30 days Expected Access Stadards If you are uable to keep a appoitmet, call your physicia as soo as possible so the time ca be made available for other patiets. Paramout Isurace Compay will ot cover claims associated with missed appoitmets. Your Primary Care Provider ca be reached 24 hours a day, seve (7) days a week. If you eed medical advice after hours, o weekeds or holidays, call your doctor s office umber. The aswerig service will take your call. Leave a message for the doctor to retur your call. Whe your doctor, the doctor who is coverig for your Primary Care Provider or a urse calls you, explai the problem clearly. They will advise you o what to do. Whe your doctor recommeds a treatmet or test, i most cases it will be covered. However, some treatmets may ot be covered or are covered oly whe authorized i advace by Paramout. Your doctor may be workig with several Paramout plas; plas are ofte differet from oe compay to the ext. The service your doctor recommeds for you may be covered uder some similar plas, but ot uder your particular pla. If you are ot sure, the best thig to do is ask Paramout Member Services. Do t be afraid to call. IF YOU HAVE A QUESTION about whether a service is covered, you ca fid out by callig Member Services. If aother doctor is coverig for your Primary Care Provider durig off-hours or vacatio, you do ot eed Paramout Prior Authorizatio before you see that doctor. But be sure to tell the doctor you are a member of Paramout Isurace Compay. You may chage your Primary Care Provider. You must otify Paramout first, before you see ay ew Primary Care Provider. Call the Member Services Departmet or through the Paramout web site at: The chage ca be made effective the day you call. You will receive a ew idetificatio card with your ew physicia s ame. If you eed to see the doctor before your card arrives, your doctor ca call Member Services to check your membership. What to Cosider Whe Selectig a Physicia or Hospital If you eed specific iformatio about the qualificatios of ay participatig physicias, you may call the Academy of Medicie, the Member Services Departmet or you may use the o-lie Provider Directory available through our web site at with liks to the Ohio State Medical Associatio. 11

16 HMO Member Hadbook The followig qualificatios are importat to cosider i selectig a Primary Care Provider or specialist: Professioal educatio medical school/residecy traiig, Curret Board Certificatio status, Number of years i practice ad Laguages spoke The followig qualificatios are importat whe selectig a hospital: The Joit Commissio status (Paramout participatig hospitals are required to have Joit Commissio accreditatio) Hospital experiece/volume i performig certai procedures. Cosumer satisfactio ad comparable measures of quality o hospitals ad outpatiet surgical facilities. If you eed a curret directory, you may request oe by callig the Member Services Departmet or you may use the o-lie Provider Directory available through our web site at Whe You Need OB/GYN Care You do ot eed Prior Authorizatio from Paramout or from ay other perso (icludig your PCP) i order to obtai access to obstetrical or gyecological care from a health care professioal i the Paramout etwork who specializes i obstetrics or gyecology. The health care professioal, however, may be required to comply with certai procedures, icludig obtaiig Prior Authorizatio for certai services or followig a pre-approved treatmet pla. For a list of participatig health care professioals who specialize i obstetrics or gyecology, cotact Paramout Member Services at (419) or toll-free A directory of Participatig Providers is also available at: If you eed more specialized OB/GYN care, the gyecologist may recommed aother participatig specialist. Whe You Are Referred to a Specialist Most of your health care eeds ca ad should be hadled by your Primary Care Provider. If your Primary Care Provider believes you eed to see a specialist - a cardiologist, orthopedist or others - your Primary Care Provider will recommed a Participatig Specialist. Or you may choose the Participatig Specialist you wish to see from those listed i the Participatig Physicias ad Facilities directory (also available o the website) ad make a appoitmet. Newly erolled members of Paramout who are already seeig a specialist should verify that the specialist is participatig with Paramout. Prior Authorizatio If a Medically Necessary covered service is ot available from ay Participatig Providers, Paramout will make arragemets for a out of pla Prior Authorizatio. Your Primary Care Provider must request a out of pla Prior Authorizatio i advace. Cosultatios with Participatig Specialists will be required before a out of pla Prior Authorizatio ca be cosidered. If Paramout approves the out of pla Prior Authorizatio, writte cofirmatio will be set to you, your PCP ad the o-participatig provider. All eligible authorized services will be covered subject to appropriate Deductible ad Copaymets/Coisurace. If you have a life-threateig, degeerative or disablig coditio that requires the services of a participatig Specialist over a log period of time, you should discuss this with your Primary Care Provider. If your Primary Care Provider ad 12

17 HMO Member Hadbook the Specialist agree that your coditio requires the coordiatio of a Specialist, your PCP will cotact Paramout. Together, you, your Primary Care Provider, your Specialist ad Paramout will agree o a treatmet pla. Oce this is approved, the Specialist will be authorized to act as your Primary Care Provider i coordiatig your medical care. Utilizatio Maagemet Participatig physicias ad providers have direct access to Paramout s Utilizatio Maagemet Departmet to authorize specific procedures ad certai other services based o medical ecessity. It is the resposibility of the participatig physicia or provider to obtai Prior Authorizatio whe required. If you experiece a Emergecy Medical Coditio after ormal office hours, you should call 911, a ambulace or rescue squad or go to the earest medical facility. You do ot eed to obtai prior approval from your PCP or Paramout. Afterward, you should otify your Primary Care Provider that you were treated. Utilizatio maagemet decisios are ot subject to icetives to restrict or dey care ad services. I fact, Paramout moitors uder-utilizatio of importat prevetive services, health screeig services (immuizatios, pap tests, etc.), medicatios ad other services to care for chroic coditios, such as asthma ad diabetes. Paramout will sed remider cards to the Member ad physicia if a claims review suggests that importat services were missed. If you eed to discuss the status of a Prior Authorizatio, you should cotact your Primary Care Provider. You may also call the Member Services Departmet at (419) or toll-free Iitial Determiatios Whe Prior Authorizatio is required, Paramout will make a decisio withi two (2) workig days from obtaiig all the ecessary iformatio about the admissio or procedure that requires Prior Authorizatio. Paramout will advise the provider of the decisio withi three (3) workig days after makig the decisio. If Paramout makes a adverse determiatio (i.e., deies approval or coverage), Paramout will otify the requestig provider i writig or electroically withi three (3) workig days after makig the decisio. Cocurret Reviews For cocurret reviews, which are requests to exted coverage that was previously approved for a specified legth of time, Paramout will make a decisio withi twety-four (24) hours after obtaiig all the ecessary iformatio. Paramout will advise the provider by telephoe or electroically withi twety-four (24) hours after makig the decisio. If Paramout reduces or termiates a course of treatmet (other tha by pla amedmet or termiatio) before the ed of such period of time or umber of treatmets, this costitutes a adverse determiatio. Paramout will otify the Member (i cases where the Member will have fiacial liability) ad requestig provider i writig or electroically withi twety-four (24) hours after makig the decisio. Retrospective Reviews Paramout will make a decisio withi twety-five (25) caledar days after receivig all ecessary iformatio o Retrospective Reviews. Paramout will otify the provider ad the Member i writig. 13

18 HMO Member Hadbook If Paramout makes a adverse determiatio, Paramout will otify the provider ad the Member i writig withi five (5) caledar days from makig the decisio. Expedited Reviews If the seriousess of the Member s medical coditio requires a expedited review, Paramout will make the decisio as expeditiously as the medical coditio requires but o later tha twety-four (24) hours after the request has bee made. Paramout will provide writte cofirmatio of the decisio withi twety-four (24) hours of receipt of the request, if the iitial decisio was ot i writig. Adverse Determiatios Paramout s writte otificatio will iclude the pricipal reaso/s for the decisio icludig specific utilizatio review criteria or beefit provisio used i makig the determiatio. Paramout will also iclude istructios for requestig a writte statemet of the cliical ratioale used to make the decisio. Paramout will provide a writte statemet of the cliical ratioale to ay Authorized Perso makig the request ad followig the istructios. Obtaiig Necessary Iformatio If a provider or Member will ot release the ecessary iformatio eeded to make a decisio, Paramout may dey approval. Eterig the Hospital Your Primary Care Provider or Participatig Specialist will make the arragemets whe you eed hospital care. Paramout Participatig Hospitals are listed i your Participatig Physicias ad Facilities directory or the Paramout web site at Show your Paramout card whe you are admitted. If you are i the hospital whe this pla becomes effective, your Paramout coverage will begi o your effective date. (The pla you had whe you were admitted should cover your hospital stay up to your effective date with this pla.) A emergecy admissio to a oparticipatig hospital must be called i to Paramout withi 24 hours (or as soo as reasoably possible) or your hospital care may ot be covered. If ad whe your medical coditio allows, your Primary Care Provider ad Paramout may arrage for you to be trasferred to a Participatig Hospital. Chage i Beefits Paramout will otify you i writig if ay beefits described i this Member Hadbook ad Schedule of Beefits chage. If a Provider Leaves the Pla If your Primary Care Provider or ay Participatig Hospital ca o loger provide medical services because their Paramout agreemet eds, we will otify you i writig withi thirty (30) days. We will cover all eligible services they provide betwee the date of termiatio ad five (5) busiess days from the date o the postmark. 14

19 HMO Member Hadbook If a Specialist Leaves the Pla If you are beig see regularly by a Participatig Specialist or a specialty group whose agreemet with Paramout eds, you ad your PCP will be otified. You may the cotact a ew Participatig Specialist for a appoitmet. Cotiuity of Treatmet If your provider s Paramout agreemet termiates ad you are udergoig a course of treatmet, Paramout will cotiue to pay for Covered Services redered by that provider util the course of treatmet is completed or util Paramout arrages for the reasoable ad medically appropriate trasfer of the treatmet to aother participatig provider. I most cases, coverage will be authorized for o more tha 90 days. If this situatio occurs, you should cotact the Member Services Departmet. Provider Reimbursemet/Filig a Claim You should always show your Paramout ID card to all providers. You are resposible for payig ay office visit Copaymets at the time you receive services. Participatig Providers must otify Paramout of the services they have redered withi 90 days from the date of service. If you have received services from a o-participatig provider, it is your resposibility to submit a claim for cosideratio. You must obtai a stadard claim form from the provider ad sed the claim to Paramout at the address below withi 120 days from the date of the service. Be sure to iclude your Paramout ID umber ad a brief explaatio of the circumstaces related to the service. Paramout Isurace Compay P.O. Box 928 Toledo, Oh Paramout will sed reimbursemet directly to Participatig Providers for Covered Services. I most cases, reimbursemet for Covered Services will be set directly to a o-participatig provider, but istead may be paid directly to you. Claims are processed withi 30 days from receipt of a fully completed claim. If ay claim is deied, Paramout will sed you a Explaatio of Beefits with the reaso for the deial. If you receive a deial o a claim ad eed further explaatio or wish to appeal the deial, you may call the Member Services Departmet for assistace. The appeal process is also described i Sectio 6 of this Hadbook. No-Covered Services If you receive services that are ot covered uder your beefit pla, you are resposible for full paymet to the provider of those services. If You Receive a Bill With the exceptio of a Deductible, Copaymets, Coisurace ad o-covered services, Participatig Providers may ot bill you for Covered Services. If you receive a bill or statemet, it is usually just a routie mothly summary of the activity o your accout. If you have ay questios about ay amout(s) show o the bill or statemet, please cotact Member Services. 15

20 HMO Member Hadbook New Techology Assessmet Paramout ivestigates all requests for coverage of ew techology usig the HAYES Medical Techology Directory ad curret evideced-based medical/scietific publicatios. If further iformatio is eeded, Paramout utilizes additioal sources icludig Medicare ad Medicaid policy ad Food ad Drug Admiistratio (FDA) releases. This iformatio is evaluated by Paramout s Medical Director ad other physicia advisors. Privacy ad Cofidetiality Paramout will keep all documeted Member medical ad persoal iformatio, whether obtaied i writig or verbally, i the strictest cofidece. Paramout will provide Members the opportuity to approve or dey the release of persoal health iformatio, except whe such release is required by law. See Paramout s Notice of Privacy Practice for more iformatio. Owership ad Physicia Compesatio Paramout Isurace Compay is a wholly owed subsidiary of the ProMedica Health System oe of the largest itegrated delivery systems i the coutry. The ProMedica Health System operates acute care hospitals, acillary facilities ad primary care ad specialist physicia practices i orthwest Ohio ad southeast Michiga. ProMedica facilities ad providers are participatig i the Paramout etwork. Paramout cotracts with Participatig Providers for health care services o a ecoomically competitive basis, while takig steps to esure that Paramout members receive quality health care. Paramout reimburses Participatig Providers through fee-for-service. Fee-for-service is the paymet of a specific amout for each specific service provided by the physicia. The amout is determied by Paramout, based o the procedure performed, ad the Paramout allowed amout for that procedure. Participatig Providers agree to accept the Paramout allowed amout (from a cotractual fee schedule) as paymet i full. Participatig Primary Care Providers are ot subject to ay risk or fiacial icetives for hospitalizatio or referrig their patiets for specialized services. Through the Paramout fee schedule, Paramout obtais discouts. Whe Coisurace is charged as a percetage of eligible expeses, the amout a Member pays is determied as a percetage of the allowed amout (fee schedule) betwee Paramout ad the participatig provider, rather tha a percetage of the provider s billed charge. Paramout s allowed amout is ordiarily lower tha the participatig provider s billed charge. Therefore, the beefit of the discout is passed o to you. Paramout also offers optioal prescriptio drug riders to employer groups. If your employer has elected to offer a prescriptio drug rider, the rider is admiistered by a pharmacy beefit maager (PBM) o behalf of Paramout. Part of this PBM service is to obtai discouts at pharmacies that cotract with the PBM. If your drug Copaymet is a percetage, the amout you pay is determied as a percetage of the discouted cost, rather tha a percetage of the retail cost. Therefore, the beefit of the discout is passed o to you. If the drug costs less tha your Copaymet, you will pay the lesser of your Copaymet or the discouted cost of the drug plus the pharmacist s dispesig fee. Uder the Paramout agreemet with the PBM, there are also certai admiistrative costs ad rebates. Neither the admiistrative costs or the rebates are icluded i your drug beefit. Paramout pays the admiistrative costs ad retais the rebates to help offset admiistrative expeses. Not all beefit plas iclude coverage for outpatiet prescriptio drugs. Refer to your Schedule of Beefits. Cotact the Member Service Departmet if you have questios. 16

21 HMO Member Hadbook Patiet Safety Paramout is workig with other hospitals, physicias ad health plas to educate our Members about patiet safety. Here is what you ca do to improve the safety of your medical care: Provide your doctors with a complete health history. Be a active member of your health care team. Take part i every decisio about your health care. Speak up ask questios. Make sure that all of your doctors kow about everythig that you are takig, icludig over the couter medicatios ad herbal/dietary supplemets. Make sure that your doctors kow about ay allergies ad reactios to medicatios that you have had. Ask for test results. Do t assume that o ews is good ews. Advise your doctor of ay chages i your health. Follow your doctors advice ad the istructios for care that you ad your doctor have agreed o. Make sure that you ca read the prescriptios you get from your doctor. Ask your doctor ad pharmacist questios about your medicatios. What is the medicatio for? What are the brad ad geeric ames of the medicatio? What does the medicatio look like? How should it be take ad for how log? What should you do if you miss a dose? How should you store the medicatio? Does the medicatio have side effects? What are they? What should you do if they occur? Whe you pick up the medicatio, ask the pharmacist if this is the medicatio that was prescribed. Make sure that you uderstad the istructios o the label. Ask the pharmacist about the best device to measure liquid medicatios. Read the iformatio that is provided by the pharmacy. It is always importat that you play a active role i decisios about your health ad your health care. Take resposibility you ca make a differece! If you ever fid yourself i the hospital, you ll likely have may health care workers takig care of you. While they make every effort to provide appropriate care, sometimes errors ca happe. By takig a active role i your care ad askig questios, you ca help make sure the care you receive is right for you. Should you fid yourself eedig hospital care, be sure to: Do your homework. Make sure that the hospital you re beig treated i has experiece i treatig your coditio. If you eed help gettig this iformatio, ask your doctor or call Paramout Member Service Departmet. See that health care workers wash their hads before carig for you. This is oe way to prevet the spread of germs at home ad ifectios i a hospital. Studies have shows that whe patiets checked whether health care staff had washed their hads, the workers washed their hads more ofte ad used more soap. Ask about services or tests. Make sure to ask what test or x-ray is beig doe to make sure you are gettig the right test. I the example of a kee surgery, be sure that the correct kee is prepped for surgery. A tip from the America Academy of Orthopaedic Surgeos urges their physicias to sig their iitials o the site to be operated o before surgery. 17

22 HMO Member Hadbook Ask about what to do whe you get home. Before leavig the hospital, be sure the doctor talks to you about ay medicies you eed to take. Make sure you kow how ofte, what dose to take, ad ay side effects to expect from the medicie. Also ask whe you ca retur to your regular activities. See if the doctor has advice o thigs you ca do to help your recovery. If you have ay questios or if thigs just do t seem right after you come home, be sure to call your doctor right away. 3. WHAT TO DO FOR URGENT CARE OR EMERGENCY MEDICAL CONDITIONS Urget Care Services URGENT CARE SERVICES meas covered services provided for a Urget Medical Coditio. A Urget Medical Coditio is a uforesee coditio of a kid that usually requires medical attetio without delay but that does ot pose a threat to the life, limb or permaet health of the ijured or ill perso. Urget Medical Coditios iclude but are ot limited to: Colds ad cough, sore throat, flu Earache Persistet high fever Mior cuts where bleedig is cotrolled Sprais Subur or mior bur Ski rash Urget Medical Coditios should be treated by your Primary Care Provider (PCP) or, i the evet your PCP is ot available, i a participatig urget care facility. You should ot go to a hospital emergecy room for Urget Medical Coditios. Services received i a hospital emergecy room for a Urget Medical Coditio without prior directio from your PCP, a participatig Paramout physicia or Paramout are ot covered. What to do: Durig office hours: Call your Primary Care Provider s office as soo as symptoms persist or worse. I most cases, your PCP will be able to treat you the same day or the ext day. If the office caot schedule you withi a reasoable time, you may seek treatmet at a participatig urget care facility or physicia s office. The service will be subject to a urget care facility or office visit copay or coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Schedule of Beefits. Participatig providers are listed i your Directory of Participatig Physicias ad Facilities or the Paramout web site at After office hours: Call the telephoe umber of your Primary Care Provider ad ask the aswerig service to have your doctor call you back. Whe the doctor or a urse calls back, explai your coditio ad the doctor or urse will give you istructios. Outside the Service Area: Call your Primary Care Provider first ad explai your coditio. If you caot call your PCP, go to the earest urget care facility or walk-i cliic. The service will be subject to a Copay/Coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Schedule of Beefits. 18

23 HMO Member Hadbook Follow-up care withi the Service Area: Your Primary Care Provider will coordiate what care you eed after your urget care services. Follow-up care outside the Service Area: Follow-up services outside the Paramout Service Area will ot be covered uless authorized by your Primary Care Provider ad Paramout i advace. ANY TIME AN URGENT CARE PHYSICIAN RECOMMENDS ADDITIONAL CARE, such as a retur visit, seeig a specialist, additioal testig or X-rays, etc., call Member Services BEFORE you get the services. Member Services ca tell you if the service will be covered, or if you eed to cotact your Primary Care Provider. Emergecy Services Emergecy Services which are required as the result of a Emergecy Medical Coditio are covered at ay medical facility, aytime, aywhere without prior authorizatio. The service will be subject to a emergecy room, urget care facility or office visit Copay/Coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Schedule of Beefits. Emergecy Medical Coditio meas a medical coditio that maifests itself by such acute symptoms of sufficiet severity, icludig severe pai, that a prudet layperso with a average kowledge of health ad medicie could reasoably expect the absece of immediate medical attetio to result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma ad her ubor Child, i serious jeopardy; b) Serious impairmet to bodily fuctios; or c) Serious dysfuctio of ay bodily orga or part. A Emergecy Medical Coditio also icludes a behavioral health emergecy where the member is acutely suicidal or homicidal. Emergecy Services meas the followig: a) A medical screeig examiatio, as required by federal law, that is withi the capability of the emergecy departmet of a hospital, icludig acillary services routiely available to the emergecy departmet, to evaluate a Emergecy Medical Coditio; b) Such further medical examiatio ad treatmet that are required by federal law to stabilize a Emergecy Medical Coditio ad are withi the capabilities of the staff ad facilities available at the hospital, icludig ay trauma ad the bur ceter of the hospital. Stabilize meas the provisio of such medical treatmet as may be ecessary to assure, withi reasoable medical probability, that o material deterioratio of a idividual s medical coditio is likely to result from or occur durig a trasfer, if the medical coditio could result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma or her ubor child, i serious jeopardy; b) Serious impairmet to bodily fuctios; c) Serious dysfuctio of ay bodily orga or part. I the case of a woma havig cotractios, stabilize meas such medical treatmet as may be ecessary to deliver, icludig the placeta. Paramout will cover Emergecy Services provided at participatig facilities. Your Pla covers Emergecy Services for a Emergecy Medical Coditio treated i ay hospital emergecy departmet. Paramout will cover Emergecy Services at oparticipatig facilities whe: 19

24 HMO Member Hadbook A prudet layperso with a average kowledge of health ad medicie would reasoably have believed that the time required to travel to a participatig facility could result i oe or more adverse health cosequeces described uder Emergecy Medical Coditio above. The determiatio as to whether or ot a Emergecy Medical Coditio exists i accordace with the defiitio stated i this sectio rests with Paramout. What to do: Iside the Service Area: I the evet of a Emergecy Medical Coditio, call 911, a ambulace or rescue squad or go directly to the earest medical facility. I the evet you are usure about whether a coditio is a Emergecy Medical Coditio, you may cotact your Primary Care Provider for istructios. Medical care is available through Paramout Physicias seve (7) days a week, 24 hours a day. Paramout will cover Emergecy Services from o-participatig providers iside the Service Area related to emergecy services. Appropriate Copays or Coisurace will be applicable. Afterward, you should cotact your Primary Care Provider for advice o follow-up care. Outside the Service Area: Call 911, a ambulace or rescue squad or go to the earest emergecy facility for treatmet. Show your Paramout card. I some cases, you may be required to make paymet ad seek reimbursemet from Paramout. Paramout will cover Emergecy Services from o-participatig providers outside the Service Area related to emergecy services. Appropriate Copays or Coisurace will be applicable. Follow-up care withi the Service Area: Follow-up medical care must be arraged by your Primary Care Provider with participatig providers. Follow-up care outside the Service Area: Oly iitial care for a Emergecy Medical Coditio is covered. Ay follow-up care outside the Service Area is ot covered uless authorized by your Primary Care Provider ad Paramout BEFORE the care begis. If you are admitted to a hospital outside the Paramout Service Area, you must call Paramout withi 24 hours or as soo as reasoably possible, or the services may ot be covered. Follow-up care must be coordiated through your Primary Care Provider. The Paramout Service Area The Paramout Service Area icludes all of Ashlad, Crawford, Defiace, Erie, Fulto, Hacock, Hery, Huro, Lucas, Mario, Morrow, Ottawa, Putam, Richlad, Sadusky, Seeca, Williams, Wood, ad Wyadot couties, ad portios of Alle, Delaware, Hardi, Kox, Lorai ad Pauldig couties. 4. YOUR PLAN What Is Covered - I Geeral Members may receive services described i this hadbook, subject to all terms ad provisios of the Group Medical ad Hospital Service Agreemet. (For details, see the Group Medical ad Hospital Service Agreemet filed with your employer.) 20

25 HMO Member Hadbook The basic steps you must take to get a doctor s care uder your Paramout pla, ad situatios i which Paramout will ot pay for care, are explaied i Sectios 2 ad 3 of this hadbook. To be covered by Paramout, the health services you receive must meet Medically Necessary criteria ad be from Paramout Participatig Providers, except i emergecies or with writte Prior Authorizatio from Paramout. What Is Not Covered - I Geeral These services ad supplies are ot covered: 1. Services by providers chose oly for coveiece (for example, if you use a oparticipatig X-ray or lab provider because their offices are earby). 2. Ay service received from ay other oparticipatig physicia, hospital, perso, istitutio or orgaizatio uless: a. Prior special arragemets are made by Paramout or b. Such services are for Emergecy Medical Coditios as described i Sectio 3/What to Do for Urget Care or Emergecy Medical Coditios. 3. Services received before coverage bega or after coverage eded. However, if coverage eds while the Member is a patiet i a hospital for a service covered by Paramout, charges related to that hospital stay will be covered accordig to the pla util the Member is discharged if the Member has o other coverage. If the Member has ew coverage, Paramout will cover up to the effective date of the ew pla. 4. No-emergecy services from o-participatig providers without Prior Authorizatio from Paramout. 5. Ay court-ordered testig, treatmet or hospitalizatio uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider. 6. Care for coditios which state or local laws require to be treated i a public facility or for which a Member is ot legally required to pay. 7. Care for disabilities related to military service to which the Member is legally etitled. 8. Care provided to Members by relatives. 9. All charges icurred as a result of a o-covered procedure. (Medically ecessary services due to complicatios of a o-covered procedure are covered.) 10. All charges for completio of reports, trasfer of medical records, or missed appoitmets. Self-help audio cassettes, videos ad books. 11. Assisted reproductive techology such as, artificial isemiatio, i vitro fertilizatio, embryo trasplat services, GIFT, ZIFT ad related services, ifertility drugs ad ay other assisted reproductive techology uless specifically required by state regulatio. 12. Surrogate paretig/pregacy icludig gestatioal surrogacy ad related services. 13. All claims for beefits submitted by or o behalf of the Member after oe (1) year from the date of service. 14. Services received i a hospital emergecy room for a Urget Medical Coditio without prior directio from your PCP, a participatig Paramout physicia or Paramout. The official terms of your erollmet ad health beefits uder Paramout Isurace Compay are stated i the Group Medical ad Hospital Service Agreemet o file with your employer. What Is Covered/What Is Not Covered - Specific Services A Copaymet or Coisurace may be required for Covered Services whe this otatio (C/L) appears. The otatio (C/L) also idicates that there may be additioal limitatios to services accordig to your employer s beefit pla. Beefit limits for Supplemetal Health Care Services may be day or visit limits or a maximum beefit limit each Cotract Year. At the start of a ew Cotract Year, beefits with limitatios will reew. See your Schedule of Beefits for your Copaymet/Coisurace requiremets ad specific limitatios o services. 21

26 HMO Member Hadbook A list of services follows, i alphabetical order: Abortio Not covered, uless medically ecessary (i.e., to save the life or protect the health of the mother). Acupucture Not covered. Alcohol abuse/addictio treatmet (See Substace Abuse Services.) Allergy testig ad therapy (ijectios) (C/L)Covered. Alterative Medicie/Therapy Not covered. Icludig but ot limited to: related laboratory testig, o-prescriptio drugs or medicies, vitamis, utriets, food supplemets, biofeedback traiig, eurofeedback traiig, hyposis, acupucture, acupressure, massage therapy, aromatherapy, Chelatio therapy, rolfig ad related diagostic tests. Ambulace (C/L) Covered whe medically ecessary ad to the earest medically appropriate facility. Not covered: Trasportatio services i o-emergecy situatios ad to hospitals beyod the earest medically appropriate facility. Asthma Supplies (C/L) The asthma supplies below are covered if the Group has purchased the optioal Durable Medical Equipmet Rider subject to the Coisurace ad limits of the Durable Medical Equipmet Rider. Peak expiratory flow rate meter (had-held), Spacers for metered dose ihalers, ad Masks ad tubig for ebulizers. Biofeedback Not covered. Blood Covered for the cost of admiistratio ad storage of blood ad blood products, whe a voluteer replacemet program is ot available. Breast Augmetatio or Reductio Not covered. Cacer Cliical Trial (C/L) Routie patiet care for Members erolled i a Eligible Cacer Cliical Trial is covered. Routie patiet care meas all health care services cosistet with the coverage uder this Pla for the treatmet of cacer, icludig the type ad frequecy of ay diagostic service, that is typically covered for a cacer patiet who is ot erolled i a cacer cliical trial, ad that is ot ecessitated solely because of the trial. Not covered: A health care service, item or drug that is: The subject of a cacer cliical trial; A health care service, item, or drug provided solely to satisfy data collectio ad aalysis eeds for the cacer cliical trial that is ot used i the direct cliical maagemet of the patiet; A ivestigatioal or experimetal drug or device that has ot bee approved for market by the Uited States food ad drug admiistratio; Trasportatio, lodgig, food, or other expeses for the patiet, or a family member or compaio of the patiet, that are associated with the travel to or from a facility providig the cacer cliical trial; A item or drug provided by the cacer cliical trial sposors free of charge for ay patiet; A service, item, or drug that is eligible for reimbursemet by a perso other tha the isurer, icludig the sposor of the cacer cliical trial. 22