Transcript HMO 101 Navigating Your Health Plan

HMO 101
Navigating Your Health Plan
UCSF HR/Benefits
Health Care Facilitator Program
2007
What Is an HMO?
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HMO stands for Health Maintenance Organization
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HMO and Managed Care are not synonymous
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An HMO provides comprehensive services for a
monthly premium through a group of providers in
a fixed geographic area
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There are open panel and closed panel HMO’s
What is the history of this form of
healthcare arrangement?
1929 – Elk City, Oklahoma: Rural farmers’
cooperative health plan. Members paid a
predetermined fee to physician. Several
hundred families enrolled.
 1929 – LA Department of Water and
Power. Pre-payment plan providing
comprehensive services for 2,000 workers
and their families. Within 5 years enrolled
12,000 workers + 25,000 dependents at a
cost of $2.69 per month/per subscriber
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What is the history of this form of
healthcare arrangement?
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During WW2, Henry Kaiser set up two medical
programs on the West Coast to provide
comprehensive health services to workers in his
shipyards and steel mills. At the end of the war,
plans opened to the public.
Other prepaid plans developed in 30’s and 40’s,
including Group Health Cooperative of Puget
Sound
1971 Nixon administration announced new
national health strategy – development of HMO’s
HMO Act of 1973 – authorized $375 million in
federal funds to help develop HMO’s.
End of 1996 over 600 HMO’s, enrolling 65 million
members
Open Panel HMO
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Your HMO and Medical Group have contractual
agreements between doctors, labs, hospitals and
other providers or facilities
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UC-sponsored open panel HMO’s (Bay Area):
Health Net
PacifiCare
(Blue Cross Plus: In Network functions like an
HMO)
How does an Open Panel HMO Work?
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You select a PCP and Medical Group to manage
your care
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PCP must be within 30 miles of work/home
Each family member may select a different PCP and/or
Medical Group
Your PCP coordinates your medical care
When you need specialty services your PCP will
refer you to a specialist, hospital or lab that is
contracted with your Medical Group
Some services must first be authorized by the
Medical Group (prior authorization)
HMO: Open Panel
Health Net
PacifiCare
(Blue Cross Plus
In-Network)
Medical Group A
Brown & Toland
Primary Care
Providers
Specialists
Medical Group B
Marin IPA
Hospitals
Labs
Primary Care
Providers
Specialists
Hospitals
Labs
How Can I Access UCSF Providers?
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Select Brown and Toland as your medical
group
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Select a PCP with a practice at UCSF who
is accepting new patients. You can
complete a provider search through the
medical plan website
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You may then be referred to specialists
based at UCSF
Closed Panel HMO
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All care is provided by employees of the
HMO
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UC-sponsored closed HMO’s include:
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Kaiser Permanente
How does it work?
You may designate a Primary Care
Provider (PCP) to manage your care but
the plan does not require this
 When your Physician determines you need
a specialized service, your Physician will
refer you to a Kaiser specialist, hospital or
lab locally
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These services are often provided in the same
building
Some services must first be authorized by
Kaiser
HMO: Closed Panel
Kaiser
Kaiser Medical Group, San Francisco
PCPs
Specialists
Hospitals
Labs
Advantages of Selecting an HMO
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Low monthly premiums
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Low co-payments
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No deductibles or co-insurance
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No claim forms
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PCP coordinates your care
Limits of an HMO Plan
Must select your PCP from the network
 PCP must refer you to a local and
sometimes limited network of
specialists/hospitals/labs
 Service area limited to certain zip codes
 Preauthorization process required for
some services
 Not all services may be covered
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Access to Services &
Covered Benefits
Services must be part of your
plan benefits and be considered
medically necessary
Access to Specialist
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In most cases, you must be referred to an
in-network specialist by your PCP
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PCP typically writes up a referral on ‘Medical
Group’ letter head and gives it to the patient
Exceptions:
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OB/GYN – You can self-refer to in-network OB/GYN
physician
Behavioral Health Services – You may contact plan
directly to access services
(Blue Cross Plus: In-Network - Direct Access Program
allows self-referral to in-network Allergists,
Dermatologists and ENT’s. Contact your Medical
Group to determine if they participate)
Access to Specialist
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Certain services must be pre-authorized
by the Medical Group or Health Plan
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PCP office will request authorization
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Review may take 5 to 7 business days sometimes
longer if additional information is needed to complete
the review
Expedited review may be granted as appropriate
You will receive letter from Medical Group or
Health Plan authorizing or denying request for
services
Out-of-network authorizations are rare
Access to Behavioral Health Services
Each plan has a mental health provider
network (also referred to as a panel)
 No need to obtain a referral from your PCP
to see mental health clinician
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You call the plan’s behavioral health unit
directly
Intake specialist will assess your needs,
authorize services and refer you to the
appropriate network providers
On-going treatment limited to “medically
or clinically necessary”
HMO Plan
Behavioral Health Networks
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Kaiser – Kaiser Mental Health Network
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Health Net – Managed Health Network (MHN)
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1-800-663-9355
PacifiCare – PacifiCare Behavioral Health (PCBH)
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San Francisco: (415) 833-2292
Or contact Member Services: 1-800-464-4000 and ask
for your local contact information
1-800-999-9585
BC Plus, In-Network – United Behavioral Health
(UBH)
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1-888-440-8225
Additional Behavioral Health Services
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UCSF Faculty and Staff Assistance
Program (FSAP)
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Provides short term assessment and counseling, and
when appropriate, coordinates referral services to your
HMO provider or other community /health care services
resources (one to three sessions
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(415) 476-8279
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http://www.ucsfhr.ucsf.edu/assist/
Access to Prescription Drugs
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Each HMO has a formulary (list of covered
drugs)
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Formularies subject to change
Non-formulary meds have higher co-pay
Must use a network pharmacy (networks
are large)
 Some meds have supply limits or require
pre-authorization
 Mail order is available
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Prescription Drug Co-Pays 2007
BC Plus
InNetwork
Rx
Kaiser
Health Net
PacifiCare
Retail
30 Day Supply
Generic - $10
Brand - $20
(Up to 100
day supply)
Non-Formularydoes not apply
Generic - $10
Brand - $20
Non-Formulary$35
Generic - $10
Brand - $20
NonFormulary - $35
Generic - $15
Brand - $25
NonFormulary-$40
Mail Order 90
Day Supply
Can be
arranged
Generic - $20
Brand - $40
NonFormulary $70
Generic - $20
Brand - $40
NonFormulary $70
Generic - $30
Brand - $50
NonFormulary $80
Where can I find specific information
about my medical plan coverage?
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Almost all the information being covered today is
outlined in your medical plan’s Evidence of
Coverage (EOC) booklet
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The EOC contains detailed information regarding
what is and what is not covered by your medical
plan
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You may review/download a copy from the ‘At
Your Service’ website or from your plan website:
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http://atyourservice.ucop.edu/forms_pubs/categorical/eoc.html
Problem Solving
What to do if you have problems
How to be proactive and self-sufficient
How to get assistance
What you can expect
First step….
Write down your list of concerns before
you make your phone call or visit
 Keep a log of communication
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Names of representatives you speak with
Dates of calls
Information provided to you
If different people tell you different things,
ask to speak with a supervisor
What if I get a bill for services?
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Typically you should not get any bills for services
received through the HMO, if you do……
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Call the customer service number on the bill and
ask, “why am I being billed”?
 Billing error - Rep may need to re-direct claim to
medical group or health plan
 Authorization issue - You may need to contact referring
physician for verification of authorization
 Eligibility issue - You may need to contact UCSF HR
and/or your health plan to verify and update your
eligibility
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Contact your health plan and let them know you have
been billed for a service that you think should be
covered
Note: A statement of services is not a bill
What if I can’t get the services I need?
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Be aware of your rights and
responsibilities as an HMO member
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Handout: “California’s HMO Guide”
What if I can’t get a timely appointment
with my PCP?
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You have the right to get health care without
waiting too long and to get an appointment when
you need one
If you can’t get an appointment within a
reasonable time frame…..
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Ask to speak to the office supervisor and firmly request
that they fit you in at an earlier date
Contact the Department of Managed Care
 1-888-466-2219
File a grievance with your health plan
Select a new PCP
Consider changing to a non-HMO health plan at Open
Enrollment
What do I do if I am dissatisfied with
the services I have received?
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Request a Second Opinion – typically
you may request a second opinion
when……
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Your PCP or Specialist gives a diagnosis or treatment
plan that you are not satisfied with
You are not satisfied with the result of a treatment you
have received
You are diagnosed with a condition that threatens loss of
limb, body function
Your PCP or Specialist is unable to diagnose your
condition
Note, your request is subject to approval and based on
medical necessity
What if I receive a denial for a covered
service?
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Request an Appeal if Your Medical Group
or Plan Denies Requested Services
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If you’ve received a denial of service, follow
the process outlined in the denial letter
The appeal process is also outlined in Evidence
of Coverage (EOC) booklet
Decision should be provided in writing within
30 days of receipt
Not satisfied with the results of the grievance
process?
Contact the CA Department of Managed Care
 1-888-HMO-2219
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What if I am dissatisfied with the plan’s
customer service?
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Submit a Complaint
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Most plans allow you to ‘call in’ to initiate the
formal complaint process, or you can submit
your complaint in writing to the plan
This process is outlined in Evidence of
Coverage (EOC) booklet
Not satisfied with the results of the grievance
process?
Contact the CA Department of Managed Care
 1-888-466-2219
 http://www.hmohelp.ca.gov/
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What if I need services which are not
covered by my medical plan?
HMOs are low cost because of limited
flexibility
 Expect to pay out of pocket for some
expenses
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Use the Health Care Reimbursement Account
(HCRA)
If you find you are paying for many
services not covered by your HMO plan,
consider switching to new plan at Open
Enrollment
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Evaluate cost vs. benefit
What if I want to change my
PCP/Medical group?
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You can change your Medical Group
and/or PCP simply by calling your HMO
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Call by 15th of month, change effective 1st of next
month
If you are currently undergoing care for an
escalated health care issue, the HMO may limit
your ability to transfer to a new medical group
What if I move out of my HMO service
area?
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Short term (vacation)
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Covered for urgent/emergency care only, when out-of-area
Ask your pharmacist about “vacation over-rides” for meds
Long term (move out of service area)
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If you move out of your service area for more than two
months, you can change to plan that provides service in the
new location
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Fill out UPAY 850 form, return to UCSF Benefits Office
Must change address in UC system (At Your Service website
and/or through your DBR)
Use the Medical Plan Wizard to find out which plans are
available in your zip code area,
http://www.webifyyourinfo.com/01291/index.php
Help is available!
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You may be able to get
information/assistance from:
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Your primary care physician or specialist office
Your HMO plan customer service
Your medical group customer service
UCSF Health Care Facilitator Program
 For escalated problems you cannot solve on your
own, contact:
 Sue Forstat, 514-3324, [email protected]
 Jason Neft, Assistant HCF, 476-5269,
[email protected]
Local Resources
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Brown and Toland Medical Group (BTMG)
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553-6748
[email protected]
UCSF Medical Center
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http://www.ucsfhealth.org/
UCSF Referral Service: 885-7777
UCSF Hospital Billing: 673-1111
UCSF Physician Billing: 353-3333
UCSF Patient Relations: 353-1936
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