Upload
jessie-pierce
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
What Is an HMO? HMO stands for Health Maintenance Organization
HMO and Managed Care are not synonymous
An HMO provides comprehensive services for a monthly premium through a group of providers in a fixed geographic area
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
What is the history of this form of healthcare arrangement?
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 Your HMO and Medical Group have contractual
agreements between doctors, labs, hospitals and other providers or facilities
UC-sponsored open panel HMO’s (Bay Area):Health NetPacifiCare(Blue Cross Plus: In Network functions like
an HMO)
How does an Open Panel HMO Work? You select a PCP and Medical Group to manage
your care 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 PanelHealth Net PacifiCare
(Blue Cross Plus In-Network)
Primary Care Providers
Medical Group ABrown & Toland
Medical Group BMarin IPA
SpecialistsHospitals
LabsPrimary Care
ProvidersSpecialists
HospitalsLabs
How Can I Access UCSF Providers? Select Brown and Toland as your medical
group
Select a PCP with a practice at UCSF who is accepting new patients. You can complete a provider search through the medical plan website
You may then be referred to specialists based at UCSF
Closed Panel HMO All care is provided by employees of the
HMO
UC-sponsored closed HMO’s include: 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 These services are often provided in the same
building Some services must first be authorized by
Kaiser
Advantages of Selecting an HMO Low monthly premiums
Low co-payments
No deductibles or co-insurance No claim forms
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
Access to Services & Covered Benefits
Services must be part of your plan benefits and be considered
medically necessary
Access to Specialist In most cases, you must be referred to an
in-network specialist by your PCP PCP typically writes up a referral on ‘Medical
Group’ letter head and gives it to the patient Exceptions:
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 Certain services must be pre-authorized by
the Medical Group or Health Plan PCP office will request authorization
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 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 PlanBehavioral Health Networks Kaiser – Kaiser Mental Health Network
San Francisco: (415) 833-2292 Or contact Member Services: 1-800-464-4000 and ask
for your local contact information Health Net – Managed Health Network (MHN)
1-800-663-9355 PacifiCare – PacifiCare Behavioral Health (PCBH)
1-800-999-9585 BC Plus, In-Network – United Behavioral Health
(UBH) 1-888-440-8225
Additional Behavioral Health Services UCSF Faculty and Staff Assistance Program
(FSAP) 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
(415) 476-8279
http://www.ucsfhr.ucsf.edu/assist/
Access to Prescription Drugs Each HMO has a formulary (list of covered
drugs) 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
Prescription Drug Co-Pays 2007
Rx Kaiser Health Net PacifiCareBC Plus
In-Network
Retail30 Day Supply
Generic - $10Brand - $20(Up to 100day supply)Non-Formulary-does not apply
Generic - $10Brand - $20Non-Formulary-$35
Generic - $10Brand - $20Non-Formulary - $35
Generic - $15Brand - $25Non-Formulary-$40
Mail Order 90 Day Supply
Can be arranged
Generic - $20Brand - $40Non-Formulary - $70
Generic - $20Brand - $40Non-Formulary - $70
Generic - $30Brand - $50Non-Formulary - $80
Where can I find specific information about my medical
plan coverage? Almost all the information being covered today is
outlined in your medical plan’s Evidence of Coverage (EOC) booklet
The EOC contains detailed information regarding what is and what is not covered by your medical plan
You may review/download a copy from the ‘At Your Service’ website or from your plan website: http://atyourservice.ucop.edu/forms_pubs/categorical/eoc.html
Problem SolvingWhat to do if you have problemsHow to be proactive and self-sufficientHow to get assistanceWhat you can expect
First step…. Write down your list of concerns before
you make your phone call or visit Keep a log of communication
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? Typically you should not get any bills for services
received through the HMO, if you do…… 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
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? Be aware of your rights and
responsibilities as an HMO member Handout: “California’s HMO Guide”
What if I can’t get a timely appointment with my PCP? 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….. 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? Request a Second Opinion – typically
you may request a second opinion when…… 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?
Request an Appeal if Your Medical Group or Plan Denies Requested Services 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
What if I am dissatisfied with the plan’s customer service?
Submit a Complaint 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/
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 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 Evaluate cost vs. benefit
What if I want to change my PCP/Medical group?
You can change your Medical Group and/or PCP simply by calling your HMO 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?
Short term (vacation) 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) 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
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! You may be able to get
information/assistance from: 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,
Local Resources Brown and Toland Medical Group (BTMG)
553-6748 [email protected]
UCSF Medical Center http://www.ucsfhealth.org/ UCSF Referral Service: 885-7777 UCSF Hospital Billing: 673-1111 UCSF Physician Billing: 353-3333 UCSF Patient Relations: 353-1936