2019 Member Quick Guide

Transcription

1 2019 Member Quick Guide

2 Inside, you ll learn about How health insurance works 3 Your Explanation of Benefits 10 My Account your total online resource 4 Important terms and definitions 11 Your member ID card 5 Frequently requested services 13 Plan networks 6 Your right to appeal 14 Know before you go 7 Notice of nondiscrimination and availability of language assistance services 15 Other ways to save 8 This is not a contract for coverage Member Quick Guide Perdue

3 How health insurance works To help you make the most of your health care plan, it s important to understand a bit about health insurance. This graphic explains how health insurance works and defines some key terms. Plan year begins January 1 Get your preventive care Need additional care? Here are some key things that you get at no charge every year: Adult physicals Well-child exams and immunizations OB/GYN visits and pap tests Mammograms Prostate and colorectal screenings Routine prenatal maternity services Pay your Copay There are several services, such as sick visits to your PCP, urgent care visits, and specialist visits that have a set fee or copay. Meet your deductible Your DEDUCTIBLE is the amount of money you must pay each year before the plan will start paying for all or part of the services. YOU PAY 100% until you meet your deductible Pay your coinsurance After you meet your deductible, you ll pay a COINSURANCE for certain covered services. YOU PAY YOUR INSURANCE PAYS Your monthly premium does not count toward your deductible or out-of-pocket maximum Member Quick Guide Perdue Reach your out-of-pocket maximum Your insurance will pay 100 percent of your covered medical expenses after you have reached your out-of-pocket maximum for the year. YOUR INSURANCE PAYS 100% Plan year ends December Member Quick Guide Perdue

4 My Account your total online resource We ve created an easy-to-use, secure section of our website where you can go to take an active role in managing your and your family s health. By setting up an account, you ll have password-protected access to help you: Search for doctors View your member ID card View your Explanation of Benefits (EOB) Track your remaining deductible Find drug pricing, pharmacy locations, and access the mail service pharmacy Check the status of your claims Complete a health risk assessment Choose to go paperless Register today at carefirst.com/perdue from your computer, tablet or smartphone and select Get Started. Or download the CareFirst mobile app. Calculate your out-of-pocket treatment costs with our Treatment Cost Estimator Member Quick Guide Perdue

5 Your member ID card Your member ID card like the example shown here identifies you as a CareFirst member and shows important information about you and your covered benefits. Make sure to always present your ID card when receiving services. If you don t have your physical card, then you can view it on your smartphone through My Account. Here are the areas of your card you ll most often have to provide when receiving care. In addition, you will find important phone numbers on the back. Make sure the information on your card is correct. If there is an error, call Member Services at the number on the back of your ID card. Member Name DOE JOHN Member ID 1 PDS Group PF10 Coverage IND 3 PCP30 SPEC50 ER100 UC30 Eff Date 01/01/19 BC/BS Plan 190/690 And You. Healthier Together. 4 This employee benefit plan provides benefits to you and your eligible dependents. CareFirst BlueCross BlueShield provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. CareFlrst BlueCross BlueShleld, the business name of CareFlrst of Maryland, Inc. is an independent corporation operating under a licens from the Blue Cross and Blue Sheild Association. 1 Member ID used to identify your coverage 2 Group # used to verify your coverage 3 Plan name and copays Customer Service: Provider Service: PRECERT & MH-SA hr FirstHelp (Nurse): Locate out of area Providers: Mental Health/Substance Abuse: Pre-Auth/Case Management: All claims should be filed to the local Plan. IND = Individual S&S = Subscriber & Spouse P&C = Parent & Child FAM = Family 4 Indicates national coverage Member Quick Guide Perdue

6 Plan networks CareFirst BlueCross BlueShield (CareFirst) has the region s largest group or network of providers doctors and hospitals who provide services covered under your plan Did you know? You never need a referral to see a specialist. In-network doctors and health care providers who participate in your plan s network. When you choose an in-network provider, you ll pay the lowest out-of-pocket care costs. Out-of-network providers and doctors who do not participate in CareFirst s networks. If you choose to receive care from an out-of-network provider, you can expect to pay more and, in some cases, may be responsible for the entire amount billed. To choose an in-network provider, log in to My Account at carefirst.com/perdue. Under the Doctors tab at the top, select Find a Doctor. Your search results will only display doctors who participate in your health plan as indicated by this icon: Member Quick Guide Perdue

7 Know before you go Knowing where to go when you need medical care is key to getting treatment with the lowest out-of-pocket costs. Perdue Wellness Centers (where available) The Perdue Wellness Centers offer convenient, affordable quality care. You can go to your appointment during work hours and not clock out. Dependent care is available for family members covered by your Perdue benefits. Medication samples and free lab work are also available. Primary care provider (PCP) Establishing a relationship with a primary care provider helps you receive consistent, quality care. Except for emergencies, your PCP should be your first call when you require medical attention. Your PCP may be able to provide advice over the phone or fit you in for a visit right away. FirstHelp free 24-hour nurse advice line Call anytime to speak with a registered nurse. Nurses will discuss your symptoms with you and recommend the most appropriate care. CareFirst Video Visit See a doctor 24/7/365 without an appointment! You can consult with a board-certified doctor on your smartphone, tablet or computer. Doctors can treat a number of common health issues like flu and pink eye. Visit carefirstvideovisit.com for more information. Convenience care centers (retail health clinics) These are typically located inside a pharmacy or retail store (like CVS MinuteClinic or Walgreens Healthcare Clinic) and offer accessible care with extended hours. Visit a convenience care center for help with minor concerns like cold symptoms and ear infections. Urgent care centers Urgent care centers (such as Patient First or ExpressCare) have a doctor on staff and are another option when you need care on weekends or after hours. Emergency room (ER) An emergency room provides treatment for acute illnesses and trauma. You should call 911 or go straight to the ER if you have a life-threatening injury, illness or emergency. FirstHelp free 24-hour nurse advice line Call anytime to speak with a registered nurse. Nurses will discuss your symptoms with you and recommend the most appropriate care. When you need care Perdue Wellness Center 1 Video Visit Convenience care centers Urgent care centers Emergency rooms Available 24/7 No Yes No No Yes Prescriptions available Yes Yes Yes Yes Yes Symptoms Preventive services $0 copay 2 $ $ $ Ear or sinus pain $0 copay 2 $ $ $ $$$ Cold or flu symptoms $0 copay 2 $ $ $ $$$ Rashes, minor burns, & minor allergic reactions $0 copay 2 $ $ $ $$$ Minor fracture, sprains, or strains $ $$$ Nausea, vomiting, diarrhea $0 copay 2 $ $ $$$ Mild asthma $0 copay 2 $ $ $$$ Foreign object in eye or nose $0 copay 2 $ $$$ Major illness or injury (broken bones, burns, bleeding) Chest pain, shortness of breath and other symptoms of heart attack or stroke 1 Where available 2 $0 copay for preventive services for associates and dependents. $15 copay for dependent sick visit. For illustrative purposes only. This information is not intended as medical advice. Amount paid will be based on deductible status and plan you are enrolled in. Note: If a dollar sign is not shown, then services cannot be performed in that setting. $$$ $$$ Member Quick Guide Perdue

8 Other ways to save Stay in your plan s network To search for a particular doctor or facility, or to find doctors in your network, visit carefirst.com/perdue and search by your plan name and your doctor s name or provider type. See doctors outside of a hospital setting Some doctors and specialists see patients in a hospital or on a hospital campus, which could mean you may receive two bills one from your doctor/specialist and one from the hospital for use of their facility. You ll save the most money when you visit a doctor located in a non-hospital setting. Take advantage of $0 preventive benefits All of our plans include many no-cost preventive services. You ll pay nothing for the following health visits when you use one of our innetwork providers: You can lower your costs when you choose: Perdue Wellness Centers In-network providers Care in a non-hospital setting Retail health clinics for after-hours care A primary care provider to manage your care Adult physicals Well-child exams and immunizations OB/GYN visits and pap tests Mammograms Prostate and colorectal screenings Routine prenatal maternity services Member Quick Guide Perdue

9 Other ways to save (continued) Flexible Spending Account (FSA) A flexible spending account allows you to use pre-tax dollars to pay for out-of-pocket qualified medical or dependent care expenses. You choose how much money you want to contribute to an FSA at the beginning of each plan year and can access these funds throughout the year. You set aside money for your FSA from your paycheck before taxes are taken out. Then, use your pre-tax FSA funds throughout the plan year to pay for eligible expenses. Your FSA funds do not roll over from year to year. However, there is a two and a half month grace period after the end of the plan year for claims to be incurred and submitted. FSA eligible expenses Medical expenses Dental expenses Vision expenses Professional services Over-the-counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc. Dependent care FSA eligible expenses Care for your child who is under age 13 Before and after-school care Baby sitting and nanny expenses Day care, nursery school, and preschool Summer day camp Care for a relative who is physically or mentally incapable of self-care and lives in your home Member Quick Guide Perdue

10 Your Explanation of Benefits After you begin using your plan benefits, CareFirst will provide you with an Explanation of Benefits (EOB). An EOB summarizes your medical care and the costs associated with the care you received. An EOB is not a bill, but will detail costs you may be responsible for under the column What You Owe. You can view your EOBs on My Account. Explanation of Benefits THIS IS NOT A BILL THIS STATEMENT REPORTS ON A CLAIM(S) WE RECENTLY PROCESSED FOR YOU AND/OR YOUR DEPENDENTS. IF YOU HAVE ANY QUESTIONS, PLEASE CALL OR WRITE: MAIL ADMINISTRATOR P.O. BOX LEXINGTON, KY Line No. Claim Detail Date of Service Service Description SAMPLE Status What Your Provider Can Charge You Your Responsibility Provider Charges Allowed Charges Co-Pay Deductible Co- Insurance Paid by CareFirst Total Claim Cost What You Owe 2/15/ Medical Care Paid $ $79.41 $50.00 $0.00 $0.00 $29.41 $ Member 2/15/2019Quick Guide Perdue Total $ $79.41 $50.00 $0.00 $0.00 $29.41 $50.94 Remark Code For illustrative purposes only. This information is not intended as medical advice. Amount paid will be based on deductible status and plan you are enrolled in. 1 Provider charges the amount billed by your health care provider(s) for your visit(s). 2 Allowed benefit (allowed charges in your EOB) the net amount a provider can charge a CareFirst member for a covered service. 3 Copay a fixed dollar amount you pay when you visit a doctor or other provider. For example, you ll pay $50 each time you visit a specialist.carefirst will start paying for part or all of the services after that. 4 Deductible the amount of money you must pay each year before CareFirst begins to pay its portion of certain claims. For example, if your deductible is $600, you ll pay the first $600 for health care services covered by your plan and subject to the deductible. CareFirst will start paying for part or all of the services after that. 5 Coinsurance the percentage you pay after you ve met your deductible. For example, if your health care plan has a 10 percent coinsurance and the allowed benefit is $100, then your cost would be $10. CareFirst would pay the remaining $ Member Quick Guide Perdue

11 Important terms and definitions Allowed benefit (allowed charges on your EOB) the maximum dollar amount an insurer will pay for a covered health service, regardless of the provider s actual charge. A provider who participates in the CareFirst BlueCross BlueShield or BlueChoice network cannot charge members more than the allowed benefit for any covered service. Copay a fixed dollar amount you pay when you visit a doctor or other provider. For example, you ll pay $50 each time you visit a specialist. Coinsurance the percentage you pay after you ve met your deductible. For example, if your health care plan has a 10 percent coinsurance and the allowed benefit is $100, then your cost would be $10. CareFirst would pay the remaining $90. Convenience care centers/retail health clinics tend to be located inside a pharmacy or retail store and offer treatment for non-emergency care no appointment required. These centers/clinics offer extended weekend hours and can often see you quickly. Deductible the amount of money you must pay each year before CareFirst begins to pay its portion of certain claims. For example, if your deductible is $600, you ll pay the first $600 for health care services covered by your plan and subject to the deductible. CareFirst will start paying for part or all of the services after that Member Quick Guide Perdue

12 Important terms and definitions (continued) Effective date the date your coverage begins. Flexible Spending Account (FSA) a tax-advantaged account that allows you to use pre-tax dollars to pay for out-of-pocket qualified medical or dependent care expenses. You choose how much money you want to contribute to an FSA at the beginning of each plan year and can access these funds throughout the year. Open enrollment the only time of year in which individuals are able to enroll or switch health plans without qualifying for a special or limited enrollment period. Out-of-pocket maximum the most you will have to pay for medical expenses and prescriptions in a calendar year. Your out-of-pocket maximum will start over every January 1. Preferred Provider Organization (PPO) PPO plans offer the most flexibility. Care can be accessed from the PPO network of approximately 42,000 providers locally and thousands nationally. Costs will be higher if you see a doctor who does not participate with a Blue Cross and Blue Shield plan. Premium the amount you pay each month for your plan, or policy, based on the plan you choose. Your premium does not count toward your deductible or your out-of-pocket maximum. Primary care provider (PCP) A provider that you select who is part of your plan s network, provides routine care and coordinates other specialized care Member Quick Guide Perdue

13 Frequently requested services We re here to help you get the most from your health plan. The following is a list of our most requested services Member Quick Guide Perdue Need to find a doctor? Have a question about your benefits? Visit carefirst.com/perdue or call Want to talk with a nurse? Call the FirstHelp 24-hour nurse advice line Need a pre-authorization and/or to talk to a CareFirst case manager? Call CareFirst BlueCross BlueShield Have a question about your mental health/substance abuse coverage? Call CareFirst BlueCross BlueShield Have a question about your FSA? Visit carefirst.com/perdue or call Want your customized health information online? Visit carefirst.com/perdue Prefer to ask your questions face-to-face? Salisbury 224 Phillip Morris Drive, Suite 106 Salisbury, MD Easton 301 Bay Street, Suite 401 Easton, MD To see a complete list of our Regional Offices, visit carefirst.com/regionaloffices

14 Your right to appeal Need to question a claim? Often, simply calling CareFirst Member Services will take care of it. If not, your next step is to submit a written appeal, within 180 days of receiving the written notification of the adverse decision, to the address listed on the back of your ID card. Or you can send a secure through My Account. The correspondence should include: Member name and ID number Provider name Date(s) of service Admission and discharge date (if applicable) A copy of the original Explanation of Benefits, voucher or bill Copies of medical records (emergency room records, X-rays, etc.) Be an informed consumer! Review additional member information: Rights and Responsibilities carefirst.com/myrights Quality of Care Complaint Process carefirst.com/qoc Privacy Statement carefirst.com/privacy Member Quick Guide Perdue

15 Notice of nondiscrimination and availability of language assistance services CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 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 Member Quick Guide Perdue

16 CONNECT WITH US: carefirst.com/perdue CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association. CST3511-1E (11/18) Perdue