2016 Quick Start Guide

Transcription

1 FOR INDIVIDUAL AND GROUP PLANS 2016 Quick Start Guide How to use your new health plan Thank you for choosing Health First Health Plans. We know sometimes health insurance can be hard to understand, but we re here to help make it easy for you. This Quick Start Guide explains how insurance works and gives you some tips on how to make the most of your plan. myhfhp.org

2 No one plans to get sick or hurt, but most people need health care at some point, and everyone needs preventive care like checkups. Health insurance helps cover these costs and offers many other important benefits. Like your home or auto insurance policies, your Health First Health Plans policy is not meant to pay for everything you may need, but it does: provide lots of programs to help you stay healthy, pay for tests that can help find problems before they get serious, pay for most of the cost of medical services and prescriptions covered under your plan, help you get the high-quality care you need at a good price, and protect you from the high cost of advanced medical care if you have a serious condition. Getting established with a Primary Care Provider A Primary Care Provider (PCP) is the doctor, physician assistant or other medical professional you see for checkups and school physicals, and usually the first provider you call for help with common problems like colds, flu symptoms, sinus infections, rashes, minor injuries, etc. Your PCP will know if your condition is more serious and you need advanced care from a specialist. Your PCP can also help coordinate your care if you re seeing more than one specialist. Family Practice, Internal Medicine, and Pediatric physicians can all serve as PCPs. Even if you re not sick, you should make an initial appointment with a PCP to become established. During this appointment, the doctor will allow extra time to collect information about your health history, order any preventive tests you need and perform a routine checkup. Although we don t require you to select a PCP, we strongly recommend you establish a relationship with one to oversee all of your care.

3 Year after year, your PCP gets to know you and your health goals, and helps you manage your overall progress. Plus, when you do get sick, it will be easier to see your PCP, rather than trying to get an appointment with a doctor who has never seen you before. You can choose to see any doctor in our network without a referral, including specialists, if they are accepting new patients. If you aren t sure which physician to choose, ask your family and friends for recommendations. You can also find information in our provider directory about each provider s medical training, certifications, additional languages spoken, as well as office addresses and phone numbers. The directory also shows which providers are accepting new patients. Your costs In-network vs. out-of-network Our Health Maintenance Organization (HMO) plans cover care provided at doctors offices, labs, hospitals, outpatient centers and other facilities who participate in our network. Our Point of Service (POS) and Preferred Provider Organization (PPO) plans also cover care given at providers in our network, but these plans include extra benefits that cover care at providers outside of our network. Note: Your ID card tells you what plan you have. Provider is a general name for the people and facilities who provide healthcare services: Doctors/physicians (MD, DO) Physician assistants (PA) Nurses, including registered nurses (RN), advanced registered nurse practitioners (ARNP) and licensed practical nurses (LPN) Physical, speech and occupational therapists Pharmacists (RPh, PharmD) and pharmacies Hospitals and outpatient surgery facilities Diagnostic testing facilities for lab tests, X-rays, etc. If you re already established with a PCP, make sure he or she is part of Health First Health Plans provider network. Tip Need a physician or other provider? Visit myhfhp.org/providers or call Customer Service. Our network includes more than 3,000 providers from Health First, Florida Hospital and many more throughout Brevard, Indian River, Volusia, Flagler, Orange, Osceola and Seminole counties. We do not have a reduced provider network for our plans with tax subsidies. No matter which type of plan you have, you can save money by using in-network providers. If you are seeing an in-network provider, you are responsible for paying only your in-network cost share. If you have a POS or PPO plan and see a provider who is not part of our network, you are responsible for paying the higher outof-network cost share. If you have an HMO plan and see an out-of-network provider, you will be responsible for the full cost of your care. Note: Emergency and urgent care is covered anywhere in the world. You pay the same amount for emergency care whether the provider is in or out of the network. Physician assistants (PAs), advanced registered nurse practitioners (ARNPs) and other providers who are not licensed as physicians offer

4 many medical services. Visits to these medical professionals require the same cost share as you would pay for seeing your physician. Urgent care centers can save you money and time If you need care quickly for a minor illness or injury and your PCP is not available, visiting an urgent care center or walk-in clinic can cost a lot less and be quicker than visiting a hospital emergency room. These facilities are usually open evenings and weekends. Tip You can also call our Nurse24 service any time toll-free at A medical professional can help you decide if you need urgent or emergency care, or to see your PCP. Five Health First Now urgent care centers throughout Brevard are staffed with medical professionals trained to treat common conditions like strep throat, minor cuts, and sprains. Walk-ins are welcome, or you can visit our website at HFnow.org and choose an estimated treatment time. When you check in online, you ll know what time a provider will be available to see you, and you can wait at home where you may be more comfortable. For more participating urgent care and walkin locations in Brevard, as well as the other counties in our provider network, see your provider directory or call customer service. Tip For serious or life-threatening emergencies, call 911 or ask someone to take you to the nearest hospital emergency department. Referrals or prior authorizations A referral means your PCP has approved you to see a specialist or participate in a program like diabetes education. We don t require you to get a referral to see any participating (in-network) providers, including specialists, for covered services. However, some specialists may require a referral from your PCP to ensure your care is coordinated properly. Some specialized services (for example MRI, PET, CT scans and nuclear cardiology studies, or non-emergency surgery) require prior authorization (approval before you receive care) by our Medical Management staff to ensure the right care is provided in the right setting. Local participating physicians are familiar with this process and can contact us for approval. If you see non-participating (out-of-network) providers, they may not be familiar with this process, but you are still responsible for making sure you receive any required authorizations. We are committed to providing you access to quality care. All decisions involving coverage are based on appropriateness of care and service. We do not compensate practitioners or any other individuals for making decisions that could result in denials of care. Denials are based on medical necessity or contract provisions. The plan works to prevent inappropriate decision-making by regularly monitoring all medical claims and requests for care. Tip Check the current Prior Authorization List at myhfhp.org/members to see if approval is required in advance. Preventive care at no extra cost Health First wholeheartedly supports preventive care the tests and services that can find problems early, even before you may start to feel sick. Finding problems early means they can usually be fixed faster, easier and cost less. All of our plans include a wide range of preventive care benefits covered at no extra cost when you see participating providers and follow established guidelines and frequency limits. Some of these services include annual well checkups for adults and children; screenings like mammograms and prostate exams; lab tests for cholesterol and

5 diabetes; vaccinations like flu shots; expectant mother exams; counseling services for alcohol abuse, tobacco use or nutrition; and many, many more. More benefits to improve your health Health First Health Plans provides a range of programs designed to help you through all phases of your health. Our Healthy Living program includes a variety of wellness services at no extra cost, such as: Fitness center membership Discounts to running and walking events and exercise merchandise Lifestyle Coaches and Nurse24 talk with experienced medical professionals by phone for reliable, proven and unbiased health information. Call toll-free Online health and decision support tools, such as articles, recipes, health track and more Chronically Well disease management and Health 360 complex case management programs help you coordinate care with your physician(s) if you have serious medical condition(s). Tip For more information on fitness center benefits and improving your health, visit myhfhp.org/fitness. Pediatric dental and vision benefits for Marketplace plans If you have a Marketplace plan (a Platinum, Gold, Silver, Bronze or Catastrophic plan), coverage for dental and vision care is automatically included for anyone age 18 and younger who is covered under your policy. When you enroll, a dental PCP from Delta Dental s DHMO network will automatically be assigned to you to ensure a provider is available when you need

6 treatment or preventive care. And if you d prefer a different dentist, it s easy to change to another one. Covered services are provided at no cost share. One routine vision exam and one pair of standard child frames with basic lenses is covered per calendar year with no cost share. What are premiums, cost shares, copayments, coinsurance, deductibles, and out-ofpocket maximums? All of these terms describe different kinds of expenses related to your insurance policy. Cost share is a general phrase that describes your share of the cost for services including copayments, coinsurance, and deductibles. A deductible is the amount you must pay before the health plan starts paying for your care. You don t have to reach your deductible before receiving preventive care. A copay is a fixed dollar amount you pay for a service (for example $10 for an office visit). Coinsurance is a percentage of the cost you pay for a service (for example 20% for an office visit). Out-of-pocket maximum is the most you will have to pay out of your pocket (deductibles, copays and coinsurance) during a calendar year. After you reach this amount, the plan will pay all of the cost for your covered care. The premium is the amount you pay each month for your insurance policy. If you get your health plan at work, your employer pays part of the premium for you, and if you get your health plan through the Marketplace, you may get tax credit to pay for all or part of your premium. The exact amount of each expense depends on which plan you choose, what kind of services you need and which providers you see. Usually plans with lower premiums have higher cost shares, and plans with higher premiums have lower cost shares. Ways to save money on your prescription costs A formulary (also called a drug list) is a list of prescription drugs covered by your plan. It includes generic and brand name medications. Most of these drugs are grouped into tiers. What you pay for the drug depends upon what tier the drug is listed in and which plan you have. To see how much drugs cost in each tier, refer to your Schedule of Benefits. To get updated information about covered drugs, please visit myhfhp.org or call Customer Service. Medications can be expensive. Our prescription benefits are designed to save you money and keep your out-of-pocket expenses to a minimum. There are several ways you can manage your prescription costs. Ask your provider which option(s) might be right for you:

7 Use Tier 1 2 generic medications when possible. Use the mail order program through Health First Family Pharmacy. You may save money by ordering a 90-day supply, and shipping is free. Ask if your prescription pills can be split in half. For some medications, pills may be available in different strengths but still have the same price. Your doctor may be able to write your prescription for half the number of pills but at double the strength. By splitting these pills in half, you still get the proper dose but may save up to 50 percent of the cost. You can often save money by comparing prices at different pharmacies if your plan includes medications with a deductible or coinsurance. For prescription drugs with a fixed copayment, your share of the cost would be the same at any of our participating pharmacies. Identity & fraud protection included at no extra cost To provide additional benefits that enhance your quality of life, we have partnered with AllClear ID, an industry leading firm to provide pre-paid access to identity theft protection and credit monitoring services. They will do the work to investigate and recover your financial losses and restore your credit report if your identity is stolen. been credited toward any required deductible. Review all EOBs closely and compare them to the receipt or statement from your provider. If you get an EOB that says we paid for a service you did not receive, please contact customer service right away. If you did not pay your share of the cost when you received care, or did not pay the right amount, you will receive a bill from your provider. We recommend keeping all EOBs for at least two years. You can also choose to receive your EOBs electronically. Your member ID card You will receive an identification (ID) card listing the member ID numbers for you and any covered dependents included in your policy, as well as our Customer Service phone number. Keep your ID card with you in a safe, easy-to-reach place, and take it with you when you travel in case of an emergency. Show this card to your healthcare provider or pharmacy whenever you need medical services or a prescription. Is an Explanation of Benefits (EOB) a bill? EOBs are NOT bills. When you receive healthcare services, you usually pay the provider a copay or coinsurance to cover your part of the cost, and the provider sends us a bill (or a claim ) to pay the remaining amount of the cost. Each time your provider sends us a claim for your care, we send you an Explanation of Benefits (EOB). It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, a description of the service, the amount billed, the amount covered, the amount we paid and any balance you re responsible for paying the provider. It also tells you how much has

8 We re here to help! By phone Call Customer Service toll-free at (TDD/TTY: ) Monday Friday from 8 a.m. to 6 p.m. Online Visit our website at myhfhp.org to find general information like provider directories, drug lists, forms, information on quality programs, member rights and responsibilities, member guidebooks, quality program updates, and our notice of privacy practices. Log in to see your personal plan documents (Schedule of Benefits, Evidence of Coverage, etc.) and benefit details, for example how much you ve paid towards your deductible, look up your claims and authorizations, etc. You can also see who is covered under your plan, print a temporary ID card or request a replacement, view member guidebooks and quality program updates, participate in the online wellness programs and more. Note: The first time you log in, you ll need your member ID number to register (set up a new account). By Please send your questions or comments to HFHPinfo@Health-First.org. In person Visit us Monday Friday (no appointment needed): In Brevard County 6450 US Highway 1, Rockledge, FL a.m. to 5 p.m. In Indian River County 2040 Treasure Coast Plaza, Vero Beach, FL :30 am to 5 p.m MPINFO160 (05/2016) Health First Commercial Plans, Inc. and Health First Insurance, Inc. are both doing business under the name of Health First Health Plans. Health First Health Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. PRSRT STD US Postage PAID Melbourne, FL Permit No US Highway 1 Rockledge, FL Log in 24/7 at myhfhp.org. Call Customer Service toll-free at (TTY/TDD: ) Monday Friday, 8 a.m. to 6 p.m.