A Health Maintenance Organization(HMO) assists with healthcare through your Primary Care Physician(PCP) that will service you so long as you stay “In Network”. That is, through your network provider, an HMO requires a PCP that will conduct and coordinate your healthcare. The selected PCP will then provide required referrals to the “In Network” specialists according to your needs. HMO’s offer competitively low copayments in similar fashion to a loyalty program. Beware when straying off your PCP’s path. Pursuing and receiving care outside of network or without a referral is costly. Other providers can charge full premiums as well as have hidden costs, ultimately leading to a hefty bill. In the event of an emergency, it is recommended to have a plan with your PCP so that a surprise doesn’t overwhelm your wallet with delayed effects.
If you select an HMO plan and are not sure which PCP is best for you there are a number of ways to select a provider. You can survey friends, family or coworkers. You can also call the medical group or IPA that you are thinking of enrollment with and describe your needs. They can often recommend an appropriate for you. If you ever need to change providers you can always do so, as long as you call the month before the requested change.
While you are required to see your PCP for all of your medical needs and receive a referral for all specialty visits, there are certain times you can self-refer. You can check with your medical group to see what its policy is, but typically you can self-refer for OB/GYN needs, as long as you choose a provider in the same group.
If you need to access urgent care, be sure to contact your medical group/IPA first. They can tell you where to seek appropriate treatment with your best interest.
Caution: Knowledge of the following tips may help your bank account stay intact
1. When you receive new ID cards in the mail, please check them closely to be sure they reflect your choice of plan. If you have chosen an HMO plan, be sure that the PCP you selected is listed on the card. If it is not, you must call the carrier immediately.
2. When you enroll in a plan each year, make sure you have a copy of the Summary of Benefits provided by the carrier. You are responsible for reading and understanding it. Be sure to pay special attention to any “exclusions and limitations”. It is sometimes helpful to bring the benefit summary with you to your provider’s office to keep a copy with you records. Even if you are not switching plans, make sure there are no mandatory or legislative changes that might affect your current plan.
3. Shortly after you enroll in a new plan, the carrier will issue an Evidence of Coverage (EOC) booklet. This is a full copy of the contract that your company has with the carrier. It will contain benefit information, as well as information on eligibility, COBRA, Coordination of Benefits, and the appeals process. The EOC will typically be sent to your HR Department which will then distribute it to the rest of the staff. If you do not receive one within a few months of enrolling, you should follow up with your Human Resources. Often the booklet is posted on a company website.
4. Try to anticipate your future needs as much as possible. Once you select a plan for the coming year, you are locked into that plan until your next Open Enrollment Period. You cannot switch plans mid-year simply if your medical needs have changed. However, if you have a mid-year Qualifying Event (new spouse, newborn child, loss of other coverage) you can certain make certain changes mid-year provided that the change is reported within 30 days.
5. Very few carriers still issue hard copy provider directories. However, if you do receive one, be aware that these are typically out of date as soon as they are printed. You would still need to confirm provider choices directly with the carrier or their website.
6. Ambulances are covered only for acute or severe emergencies. They are not covered as a means of simple transportation to the local hospital for a minor issue. You will be responsible for any charges not covered by your insurance, even if you did not summon the ambulance yourself. Once in the ambulance you will not be given a choice of hospitals-the ambulance crew will either take you to the closest or most appropriate hospital for your condition. You or a family member will need to contact your carrier to let them know that you are in the hospital to allow them to coordinate your future care.
7. The Affordable Care Act now mandates that most plans cover routine physicals at no charge when obtained in network. However, it is important to understand two things in relation to this. A. A routine physical means that you have no complaint of illness or injury at the time of the visit. If you tell your provider that you knee hurts, this visit will not be coded as a routine physical and regular copays would apply. B. Not all exams and associated tests performed during a routine physical are covered by the ACA mandate. For a complete list of what tests or procedures are mandated to be covered at no charge and other associated information, please check with the carrier.
8. A frequent source of confusion concerns what treatment an office visit copay will cover. Typically the office visit copay covers a discussion with your doctor as to your chief complaint, a simple exam and a prescription. Lab work, X-Rays and minor surgical procedures are beyond the scope of what an office visit copay will cover and may involve additional costs.
9. If you are traveling outside of the United States, typically only true emergencies/urgent care issues are covered and at the closest locale where you can obtain standard treatment. Usually, you will have to pay the provider in advance and be reimbursed by the carrier later. Therefore it is very important to obtained detailed bills to submit to the carrier. The bills should include your name, the date of service, the provider, the location of the service, the diagnosis and the treatment performed. The carrier will not be able to reimburse you if you only have a credit card or payment receipt. Before you travel, it is useful to contact the carrier to see if they have any recommended or contracted providers in the country you will be visiting. If you are hospitalized, be sure you or someone in your party contacts the carrier so that the carrier can coordinate your care.
10. If you have a dependent living outside of your home, call the carrier to see if and how that dependent would be able to access care. Typically, if you are in a PPO plan, that dependent would still have full access to care anywhere in the United States. If you select an HMO plan, accessing care outside of the service area will vary based on the specific carrier.
Jay is a graduate of the University of Pennsylvania School of Dental Medicine and also has an MBA from San Francisco State University. He has worked for a number of insurance carriers and brokers over the past 25 years. At UBF, Jay specializes in advocating for our clients in various issues, including grievances, benefit inquiries and eligibility issues.