Your guide to your health plan

Transcription

1 Health Plan, Inc. Your guide to your health plan

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3 Welcome to Presbyterian. We are glad to have you as a member, and we look forward to being your partner in good health. In this booklet you will find essential information about your health plan benefits, plus tools and resources to help you manage your healthcare. Understand how your health plan works before you need it. This guide is a brief summary, not a comprehensive description of benefits, limitations and/or exclusions. For complete information, please refer to your member materials. You can find your member materials in your mypres account. Log in to mypres at

4 Your ID card(s) Please find your Identification (ID) card(s) attached to the back of this booklet. Remove the card and keep it with you. You will need to have it whenever you go for medical care. Please check your ID card to be sure the information is correct. If anything on the card needs to be changed, please call the Presbyterian Customer Service Center at the number located on your ID card. We will be happy to help you. Your primary care provider You and all covered members of your family should choose an in-network primary care provider (PCP) to handle your healthcare needs. Connecting with your PCP is a vital part of your healthcare. Your PCP treats you when you are ill, helps you from getting sick or injured, and helps you plan a healthier life. Your PCP learns about your health record so that he or she can talk to your health concerns or help you find the right place for the care you need. PCPs can include the following: General or family practice doctors Internists (internal medicine doctors) Pediatricians Obstetricians/gynecologists Nurse practitioners or physician s assistants Find a PCP by using Presbyterian s provider search tool at or by calling customer service.

5 Annual Deductibles and Out of Pocket Maximums Annual Deductible Annual Out of Pocket Maximum Single 2-party Family Single 2-party Family $325 $650 $975 $3,500 $7,000 $10,500 Office Visits Plan Benefit / Coverage In-Network Member Costs Subject to deductible Prior authorization required Preventive Care No charge No No For a complete list of preventive services, visit Exams, immunizations, etc. for services that are not medically necessary, such as licensing, certification, employment, insurance and foreign travel are not covered. Primary Care Provider Visits $25 copay/visit No No Specialist Provider Visits $40 copay/visit No Presbyterian does not require you to get a written referral to see a specialist. However, some specialists may require referrals even if PHP does not. You should talk to your PCP about any specialists you plan to visit. Video Visit No charge No No Must use designated Practitioner/Provider. Behavioral (Mental) Health Provider Visits $25 copay/visit No Maternity Care Pre- and Postnatal $25 copay initial visit No charge thereafter Delivery subject to inpatient cost sharing and prior authorization. Elective home births and services are not covered. Be sure to enroll your newborn in your health plan within 31 days of birth. On-campus Student Health Center No $25 copay/visit No No Urgent Care Facility $50 copay/visit No

6 Emergent, Inpatient, and Outpatient Care Plan Benefit / Coverage In-Network Member Costs Subject to deductible Prior authorization required Emergency Room Visit $175 copay/visit No ER copay waived if admitted into a hospital then hospital copay will apply. Emergency Medical Transportation $30 copay/trip ground $100 copay/trip air No Copay waived if admitted into a hospital. Sometimes it is necessary to get urgent or emergent care from an outof-network provider. You will save money if you receive your follow-up care from an in-network provider. Hospital Inpatient Stay Physical, Mental, and Substance Abuse $500 copay/ admission Certified Hospice Care No charge No Skilled Nursing Care $500 copay/ admission Copay waived if readmitted within 15 days. Home Healthcare $40 physician copay; No charge nursing service Outpatient Surgery 20% facility copay, No No No charge physician copay Cardiac Catheterization 20% No Lab Infertility Services Copay based on (limited services) place of service Dialysis No charge No Durable Medical Equipment 20% Such as diabetes supplies, orthotic appliances, prosthetic devices.

7 Diagnostic Services, Rehabilitation, and Therapy Plan Benefit / Coverage In-Network Member Costs Subject to deductible Prior authorization required Laboratory Tests 20% No If your provider sends out lab work, be sure the laboratory is innetwork. Using an in-network provider or facility saves you money. Radiology, X-ray, Ultrasound 20% No Imaging and Scanning (PET, CAT, MRI) Home / Sleep Studies (2 nights) Gastrointestinal Lab Procedures (such as GI tests and endoscopies) Allergy Testing and Serum (Extracts) 20% up to maximum of $200 per test/day 20% No 20% No $40 copay No Outpatient Speech, Physical, or Occupational Therapy Chiropractic and Acupuncture $40 copay/visit No $40 copay/visit No Limited to 20 visits combined per plan year. These services and other complementary therapies (e.g., massage) are limited. Please refer to your Summary Plan Description. Cardiac Rehabilitation $40 copay/visit No Pulmonary Rehabilitation $40 copay/visit No Radiation Therapy and Chemotherapy No charge in Physician s office No

8 Prescription Coverage Your pharmacy benefits are administered by Express Scripts. To get details on your coverage please call Express Scripts at Urgent and Emergent Services Presbyterian covers urgent care and emergency services whenever and wherever you need them. You may go to any facility that provides urgent or emergency care services inside or outside of New Mexico. When receiving urgent care or emergency services outside of New Mexico, you can help reduce costs by seeking care from our national health care provider network. For additional information regarding our national network, please call customer service or visit our Health Plans section on phs.org. In addition to urgent care and emergency services, any medical service provided by a national network provider will be covered at the in-network benefit level. This means that you will pay the in-network cost sharing amounts listed on your benefit summary.

9 Understanding how your cost sharing works You don t need to be surprised by your costs when you receive medical care. Several factors can determine your financial responsibility, and below are some important insurance terms to know related to those costs: Deductible: The amount that you pay before your plan pays. The deductible does not apply to all services. Out-of-pocket maximum: The maximum dollar amount that you will pay in a plan year for covered services. All out-of-pocket costs for covered services go toward your maximum, such as copayments, coinsurance and deductibles. After you have met the out-of-pocket maximum, the plan will pay 100 percent of covered services. Coinsurance: The percentage amount of a covered healthcare service that is partially paid by you and partially paid by the health plan. Copayment (copay): The fixed dollar amount you are required to pay for a healthcare service. Allowed amount: The amount that the health plan agrees to pay a provider for a service. It is usually less than the total amount billed and can be considered the member discount before cost sharing begins. Out-of-network provider: A provider (doctor, facility, etc.) that does not have an agreement with Presbyterian for reimbursement of services to health plan members. Balance billing: The process of billing a patient for the difference between the medical service provider s actual charges and the amount that the provider will be reimbursed from the patient s insurance benefits plan. Reasonable and customary: The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. This amount is used to determine the allowed amount, especially when paying out-of-network providers.

10 Use the Treatment Cost Calculator to estimate out-of-pocket costs Presbyterian s Treatment Cost Calculator is designed to help you estimate what your out-of-pocket costs could be before you have treatment(s) or undergo procedures. Go to the treatment cost calculator for estimates of treatment costs based on your own personal plan benefits, deductibles and out-of-pocket maximums. Find the calculator by logging in to mypres; under My Health plan quick links, select Look up a medical cost estimate. Some healthcare services require prior authorization Some healthcare services such as hospital admissions or surgeries as well as some medical supplies and medications require approval from Presbyterian before you can receive them. This is called prior authorization. Your in-network provider is responsible for obtaining any needed prior authorization for you. If your service is not approved, Presbyterian will send you a letter explaining why. The letter will also inform you of your right to appeal this decision and give you instructions on how to do so. Visit for more information on the difference between a prior authorization and a referral.

11 Cost sharing example Note: This chart is for illustrative purposes only and does not reflect your plan s cost sharing amounts. This example is for in-network providers. Total billed charges Allowed amount Deductible owed Amount owed after deductible Member coinsurance / copayment Plan pays Total amount member pays $2,500 Total amount for service (without plan discount). $2,000 Amount plan and provider agreed on per contract. $100 This would be $0 after individual or family deductible is met (or if your plan does not have a deductible). Sometimes deductibles do not apply to all services. $1,900 Allowed amount minus deductible owed. $380 In this example the member pays 20%. If copay, this would be a flat dollar amount. $1,520 Plan pays remaining 80%. If copay, plan pays remaining balance after copay. $480 Deductible owed + coinsurance or copay. We also recommend you watch a short video explaining how cost sharing works at videos, and you are always welcome to call your customer service team with questions.

12 How a family deductible works Note: If your plan does not have a deductible or you are on your plan as an individual, please disregard this example. If you have family coverage, any combination of family members can satisfy the deductible, but no one member can contribute more than his or her individual amount. Once a member meets his or her individual amount, that deductible is considered met. Family out-of-pocket maximums work the same way. Remember, the out-of-pocket maximum includes all costs for covered services, including deductibles, copayments and coinsurance. Here s an example of a four-person family that has a health plan with a $2,000 individual deductible and a $4,000 family deductible. The father has a $3,000 medical bill. Now the mother has a $1,000 medical bill and the son has a $500 medical bill. Then, say the daughter has a $1,000 medical bill. This means he s met the $2,000 individual deductible amount, so the insurance company will help pay for the remaining $1,000 of that bill and any other covered medical services for him during the year. They are still $500 short of the family deductible. They would pay their entire bills out of their pockets because they have not reached their individual deductibles. The first $500 would go toward the daughter s individual deductible and the remaining $500 on the family deductible. The insurance company would pay the other $500, since the family deductible has been met, as well as any subsequent covered medical spending for the entire family throughout the rest of the plan year.

13 The claims process From the day of your doctor s appointment or other medical service to receiving your Explanation of Benefits (EOB) in the mail, this is how Presbyterian processes your claims: 1. You present your ID card at the doctor s office. 2. After your visit, your doctor s office will send us a claim. A claim is a request for payment that you or your provider submits to your health insurer when you receive services or items you think are covered. 3. We process your claim according to your plan s benefits. 4. We send you an EOB that explains how your claim was processed. We send a statement, along with any applicable payment, to your doctor s office. 5. Your doctor may bill you for any remaining balance, depending on your plan s benefits. If you have any questions or concerns, you can always call customer service. Tip: Review your EOBs carefully. EOBs tell you what your plan has paid on your behalf and exactly what you should be paying for healthcare services (this is called cost sharing).

14 If you have a complaint: grievances and appeals We are committed to providing you with high-quality care and service. If you re not satisfied, we want to know. There two types of complaints you can file if you are not satisfied with the coverage of your services or with your care: Grievance An official notice of your dissatisfaction with your health plan or your care. You must file your grievance within 30 calendar days of the date that you had the problem. Most grievances take up to 30 days to resolve. Appeal A formal request for review of a decision or action that Presbyterian has made that affects your healthcare, e.g., a denial or limitation of a service. You must file your appeal within 90 calendar days of the date that you received notice of Presbyterian s decision. Most appeals take up to 30 days to resolve. If you believe your health will be in danger if you wait that long, you may ask for an expedited appeal. You can file a grievance or an appeal in one of three ways: to info@phs.org Submit online at (search for Appeals) Write to: Presbyterian Health Plan, Inc. Appeal and Grievance Department P.O. Box Albuquerque, NM The Managed Health Care Bureau of the Office of the Superintendent of Insurance is also available to assist you with grievances, questions, or complaints. Contact them at ASK-OSI ( ).

15 Direct access to medical advice 24 hours a day, 7 days a week, 365 days a year Whenever you have a healthcare question, call the nurse advice hotline toll-free , around the clock, every day of the year. Registered nurses offer you suggestions for self-care measures and provide general health information on a broad range of healthcare topics. Find the information you need, when you need it, at phs.org. Explore the resources available to you by visiting There you will find forms and documents, FAQs, member newsletters and more. From phs.org, you can also log in to your mypres account. mypres provides you with secure, 24-hour access to your health plan information and memberexclusive tools and resources.

16 An important eco-friendly feature of mypres is the ability to view and print your health plan benefit materials. You will no longer automatically receive paper copies of your benefit materials. Please contact customer service if you would like to receive a copy at (505) or , TTY: Through mypres, you also can: Check how much of your deductible you have met Review your claims history and Explanation of Benefits (EOBs) Print a temporary ID card and request a replacement Look up a medical service cost estimate using our Treatment Cost Calculator Manage your prescriptions locate pharmacies, check your medication claim history, and more Schedule a video visit MyChart helps improve communication between you and members of your Presbyterian Medical Group (PMG) care team. This service is only for members seen by PMG providers. MyChart located within mypres will allow you to view parts of your electronic health record as well as: View test and lab results Request an appointment Send messages to your care team Review summaries of recent visits The benefit information provided is a brief summary, not a comprehensive description of benefits, limitations and/ or exclusions. For complete information, please refer to your member materials, which can be found online at You also may call customer service. MPC091498