An EPO Employee and Retiree Medical Plan...

Transcription

1 An EPO Employee and Retiree Medical Plan... Member Handbook...with PPO Benefit Option The benefits and service you love. Plus.

2 IMPORTANT CONTACT INFORMATION PLAN INFORMATION AND MEMBER SERVICES Office Phone: (661) or 1 (855) 308-KLHP (5547) option 1 then 5 24/7 Nurse Advise Line: (661) or 1 (855) 308-KLHP (5547) option 1 then 2 Fax: (661) Plan Website: Office Location and Lab Draw Station: KLHP@kernlegacyhp.com Kern Legacy Health Plan 1115 Truxtun Ave, 1st Floor Bakersfield, CA Office Hours: Monday - Friday, 8:00 a.m. - 5:00 p.m. Lab Hours: Monday - Friday, 7:30 a.m. - 11:30 (lab hours are subject to change) UTILIZATION MANAGEMENT: AUTHORIZATIONS AND REFERRALS Office Phone: (661) or 1 (855) 308-KLHP (5547) option 1 then 3 Fax: (661) CLAIMS QUESTIONS AND INFORMATION Office Phone: (661) or 1 (855) 308-KLHP (5547) option 1 then 1 Fax: (661)

3 TABLE OF CONTENTS Welcome to Kern Legacy Health Plan Network Plus. 2-4 Handbook and Kern Legacy Member Services Line. 2 Kern Legacy Health Plan Network Plus Website. 2 Member Identification Card 2-3 How Does Kern Legacy Health Plan Network Plus Work? Accessing Care Primary Care. 4 Referral and Authorization Process 4-5 Services Radiology and Laboratory Services 5-6 Surgeries and Procedures. 6-7 Urgent and Emergency Coverage 7 Pharmacy 7-8 Tips For Transitioning From Another County Health Plan 9 Kern Legacy is giving you the care you need without the high premiums. Take advantage of both the EPO and PPO benefit levels and only pay up for the services you choose.

4 Handbook and Kern Legacy Member Services Line This member handbook provides you with valuable information about the health plan, managing your healthcare coverage, and accessing services. If you have any questions or need assistance, Member Services is available to help you during normal business hours. If you have any questions about your health and your doctor is not available cal1 our 24/7 Nurse Advice Line and speak to a registered nurse. You can also listen to prerecorded information on important health topics. Bakersfield Area: (661) Outside of Bakersfield: 1 (855) 308-KLHP (5547) Welcome to Kern Legacy Health Plan Network Plus Option 1 for Members and then... Option 1: Option 2 : Option 3: Option 4: Option 5: Claims 24/7 Nurse Advise Line Authorizations and Referrals Medication questions or to speak with a Pharmacist Member and Provider Service Kern Legacy Health Plan Network Plus Website The website is a great way to get the information you need quickly. Visit for the following information: Plan Overview EPO and PPO Level Benefits Summary of Benefit and Coverage Summary Plan Description Out of Pocket Expenses Plan Information Provider Directories Instructions for Accessing Care Authorization and Referral Process Continuity of Care Member Identification Card Each member will be given a member identification (ID) card which will contain a unique member ID number and other important information about your medical and pharmaceutical benefits. You will need to present your member ID card along with a picture ID when accessing both medical and pharmaceutical services. All new members will receive an ID card in the mail within seven to ten 2

5 business days of becoming a member. If you do not receive your card or need a replacement card, contact Member Services at (661) Possession of a member ID card does not guarantee eligibility or payment of services. How Does Kern Legacy Health Plan Network Plus Work? With Network Plus, Kern Legacy offers members a traditional Exclusive Provider Organization (EPO) model health plan with a PPO Benefit option that allows for access to care beyond the EPO. Essentially, this means members have two tiers of benefits available in one health plan. EPO Level Benefit. Within the EPO level benefit, members must receive care from EPO level providers. The EPO Level network of providers includes Kern Medical specialists providing services through Kern Medical hospital and off-site medical offices, as well as locally contracted physicians to provide primary and specialty care services not provided by Kern Medical. The EPO Level network also includes providers and facilities in the outlying areas of Kern County. Kern Medical can provide the following services (some of which are exclusive to Kern Medical): Cardiopulmonary Services Labor and Delivery Podiatry Emergency Services Laboratory Radiology Gastroenterology Neurosurgery Rheumatology General Surgery Outpatient Surgery Some Chemotherapy Hospital and Inpatient Services Otolaryngology Specialty Care Infectious Disease Pharmacy Urology Inpatient Psychiatric Plastic Surgery (not all services available at Kern Medical are listed above) All your healthcare needs can be met on the EPO Level Benefit including Primary Care, Specialty Care, Mental and Behavior Health, Emergency Care, Urgent Care, Hospital and Pharmacy. EPO Level Benefit Out-of-Pocket expenses. Low to no copays will apply to all services on this benefit level. There are no copays for many of the services provided at Kern Medical. There is also no deductible or coinsurance applied to this benefit level with the exception of a 50% coinsurance for infertility testing. PPO Level Benefit. When you choose to use providers or facilities outside of the EPO Level network, the PPO Level benefit offers an additional network of providers including specialty care, lab and radiology, and hospital services. All PPO Level network providers are located within Kern County. 3

6 PPO Level Benefit Out-of-Pocket expenses. A deductible must first be met when accessing services on this benefit level. Once the annual deductible is met, the plan will cover 80% of our negotiated rate for those services and the member will be responsible for the remaining 20% as their coinsurance. This applies to all services in the PPO Level only. Contracted providers may change during the year. This can happen for many reasons, including a provider s retirement, relocation out of area, failure to continue meeting credentialing standards, or if the provider is unable to reach a contract agreement. Accessing Care Primary Care Each covered member must select a Primary Care Provider (PCP). Family members are not required to be assigned to the same PCP. The EPO Level listing for PCP s consists of family practitioners, general practitioners, internists, and pediatricians. When a consultation with a specialist is necessary, the PCP will refer the member to one within the EPO Level network. The relationship with a PCP is very important, since it is your PCP that will coordinate your health care under this plan. If you do not choose a PCP at time of enrollment, one will be assigned to you. You may change your PCP at anytime by contacting Member Services at (661) Where do I find a list of PCP s? The EPO Level Provider Directory includes a list of participating Primary Care Providers. It can be found online at or by contacting Member Services. What if I am electing a new PCP? If you are electing a new PCP, be sure to contact that physician s office to verify that he/she is accepting new patients. You should also make an appointment for an initial health assessment (IHA). This first meeting will be an important time for you and your PCP to get to know each other and review your health status. Referral and Authorization Process EPO Level Benefit. Prior authorization is required for most EPO Level specialty referrals, as well as for certain procedures, surgeries, durable medical equipment, and radiology services. Referrals to specialists must be initiated by the PCP. Authorizations for procedures and services must be initiated by an in-network provider. PPO Level Benefit. Initial consultation with PPO Level providers can be done on a self-referral basis, meaning that your PCP does not have to submit a referral, but for the initial consultation only. Any additional follow up care and certain procedures will require prior authorization from the Plan. The authorization request will be submitted by the PPO Level provider. 4

7 Referrals are not required for: OB/GYN, Chiropractic Care, Mental Health Outpatient Services (except Intensive Outpatient or IOP ), and for a Physical Therapy Evaluation. Once requests are received and all the necessary clinical documentation is obtained, the Utilization Management (UM) department will review the request to determine medical necessity. How will I know if my services have been authorized? You will be notified by mail of the determination for approval or denial of the referral or authorization request. The requesting provider will be notified by fax. How long does it take to process a request? Requests take up to three business days from the date that UM receives the completed request and the supporting documentation. Urgent requests will be expedited based on medical necessity. What if I do not have a prior authorization and receive services? Any visits or services that require prior authorization under the plan s guidelines cannot be provided until prior authorization is obtained. If services are provided without authorization there will be no coverage by the plan. Radiology and Laboratory Services Radiology and laboratory services can be provided by in-network providers only, which includes your physician office (lab and plain film x-rays only) and EPO and PPO Level providers. Although Kern Medical is not your only option, both laboratory and radiology services are available at Kern Medical s main campus, Sagebrush, and lab services downtown at the Kern Legacy office. Information on Kern Medical radiology and laboratory services are listed below. (Not all services are available at each location.) Kern Medical-Main Campus: 1700 Mount Vernon Ave, Bakersfield CA Radiology - 1st Floor, Room 1132 Monday - Friday, 8:00 AM - 5:00 PM Phone: (661) Fax: (661) Services: Routine and complex x-rays, CT scan, MRI, ultrasound, mammography, biopsy and nuclear medicine services. (Cannot do PET scans or Bone Marrow Biopsy). Services Scheduled appointments: All services other than plain film x-rays require an appointment. Call (661) to make an appointment. On the day of the appointment, report directly to Radiology department. Walk-ins: You must register in A-Wing, located on the 1st floor, before services can be provided. Once registered, report to the Radiology department. Only plain film x-rays can be performed on a walk-in basis. 5

8 Laboratory - 1st Floor, D-Wing Phone: (661) Services: Laboratory testing including blood tests, urinalysis, tests on tissue specimens, and screening tests (including prenatal glucose testing). Sagebrush: 1111 Columbus St, Bakersfield CA Radiology - Monday - Friday, 8:00 AM - 5:00 PM Phone: (661) Services: Routine x-rays only (including chest, spine, and extremity). Walk-ins only at this location Laboratory - Monday - Friday, 7:30 AM - 4:30 PM Phone: (661) Downtown Draw Station: 1115 Truxtun Ave, Bakersfield CA Laboratory - Kern Legacy Office, 1st Floor Phone (661) Monday - Friday, 7:30 AM - 11:30 AM (hours subject to change) Services: Blood tests and urine only. No appointment necessary. Please make sure to bring your lab and/or radiology orders to the visit. Orders must be signed by the physician and a diagnosis must be included. See the Provider Directories for a complete list of EPO and PPO providers. Surgeries and Procedures Surgeries and procedures will be performed at Kern Medical or an affiliated offsite facility by a Kern Medical physician and/or another network provider with Kern Medical privileges. Surgeries and procedures not performed at Kern Medical must be performed at another EPO or PPO Level outpatient surgery center or hospital facility. Services will not be covered at a non-contracted facility unless it is the Plan that is directing and authorizing care. Endoscopy Services. All preventative and/or screening colonoscopy and endoscopy services requested by a PCP will be performed at Kern Medical by a Kern Medical specialist. Endoscopy services requested by an EPO or PPO Level network gastroenterologist must be performed and an EPO or PPO Level network facility. Labor and Delivery. All labor and deliveries (including scheduled C-sections and inductions) in the greater Bakersfield area will take place at Kern Medical, unless the member chooses to receive care at a PPO Level hospital. If a member is being seen for pre- and postnatal care by a non-kern Medical physician, who does not have privileges at Kern Medical, the on-call or attending OB/GYN will deliver the baby at Kern Medical. Patients needing observation should be sent to Kern Medical under the EPO Level benefit. For labor and deliveries in the outlying areas, please refer to the provider directory for contracted facilities. 6

9 If you have questions, please call Member Services at (661) Urgent and Emergency Coverage The Plan has urgent and emergency coverage included as part of the EPO Level benefit. The Plan only pays for Emergency Room (ER) visits for true emergencies. Less serious issues should be treated at an urgent care facility. Urgent care facilities are available throughout Kern County on the EPO Level network. The only EPO Level network hospital facility in the Bakersfield area is Kern Medical. For a complete list of urgent cares and other EPO and PPO Level network hospitals (including the outlying areas), refer to the Provider Directory on or contact Member Services. ER vs. Urgent Care. For life-threatening emergency situations, the ER is the only option. Emergency situations involve conditions that place the health of an individual in serious jeopardy, or result in the dysfunction of any body organ or part. Less serious conditions requiring immediate attention should be treated by a primary care provider or at an urgent care. 24/7 Nurse Advice Line. If you need medical advise, contact our Nurse Advice Line and speak to a registered nurse day or night. You can also listen to recorded information on important health topics. To reach our 24/7 Nurse Advice Line call: (661) or 1 (855) 308-KLHP (5547) and select options 1 then 2. When to go to an Urgent Care When to go to an ER Your PCP is not available Broken bones, sprains and strains Fever or flu-like symptoms Coughs, colds, sore throats Rash or other skin irritations Mild asthma Ear infections Allergic reactions (non-life threatening) Difficulty breathing Loss of consciousness Severe bleeding Sudden loss/blurred vision Chest pain Heart attack or stroke Head injury Other major trauma Pharmacy WellDyne is the administrator of Kern Legacy s prescription drug program with a three-tiered structure to offer you access to generic, preferred brand, and nonpreferred brand medications. Prescriptions should be filled through a Kern Medical affiliated pharmacy in order to purchase up to a 90 day supply of medication for either no copay or reduced copay. However, you can choose to use any retail pharmacy for a higher copay. Generic medications at a retail pharmacy have a $5 7

10 copay. You can only get a 30-day supply of medication at a retail pharmacy. Getting a prescription filled at Kern Medical: Allow 2-3 hours after prescription drop off for pick up. To ensure that medication is ready, contact the pharmacy prior to pick up. Employee Medical Plan at a Kern Medical Pharmacy $ 0 copay - generic $ 15 copay - preferred brand $ 35 copay - non-preferred brand Retiree Medical Plan at a Kern Medical Pharmacy $ 0 copay - generic $ 20 copay - preferred brand $ 40 copay - non-preferred brand Refills: Call the Kern Medical pharmacy location you originally used. Existing refills, not transfers, require the 6 digit RX number. To ensure that medication is ready, contact the pharmacy prior to pick up. Prescribing Physician Fax/E-script: Contact the pharmacy to verify that the prescription was received and to arrange for pick up at that location, or to select another delivery method. Do I have to go to a Kern Medical pharmacy to pick up my medications? You can go to a Kern Medical pharmacy to pick up medications or you can take advantage of the following options: Direct to Desk delivery. Kern Medical will deliver your medication directly to your County office. For a current list of office delivery locations and for more information on how to get desk delivery started call (661) FedEx Delivery. Kern Medical can also have your medications delivered to your home by FedEx at no additional cost. You must contact the pharmacy to request this service. FedEx delivery dates vary. A signature is required upon delivery. Two delivery attempts will be made before items are returned to the pharmacy and arrangements will have to be made for pick up. Prior Authorizations. Some medications may require Prior Authorization to establish medical necessity. These authorizations are processed by WellDyne. Kern Medical Main Campus Pharmacy 2014 College Ave Bakersfield CA Phone (661) Refills (661) Fax (661) Sagebrush Pharmacy 1111 Columbus St Ste 2000 Bakersfield, CA Phone (661) Refills (661) Fax (661)

11 Tips For Transitioning From Another County Health Plan If you are currently undergoing treatment or have a scheduled surgical procedure with a non-network specialist: Complete a Continuity of Care form which can be found on the plan website: This form is a request for continued services with a non-network provider, not an authorization for services. The Utilization Management department will contact you regarding your continuity of care request. Do not continue care with the non-network provider until you have received proper authorization from the plan. Continuing treatment without authorization may result in no coverage under the Plan for services provided. If you are currently undergoing treatment or have a scheduled surgical procedure with an in-network specialist: Notify Kern Legacy immediately. All authorizations issued under your previous health plan will expire on the disenrollment date of that health plan. To ensure that your care will not be delayed, Kern Legacy will need to generate an authorization under our plan and provide this to you and your provider. Continuing treatment without authorization from Kern Legacy will result in no coverage under the Plan for services provided. If your PCP is remaining the same under Kern Legacy as your previous Plan: Notify your PCP that your insurance has changed and provide your PCP with a copy of your new member ID card and insurance information. If your PCP does not update your insurance information and bills the previous plan, your claims will be denied by your old plan and this will create delays in payment. If you have selected a new PCP: Sign a release form with your previous provider to ensure that your new PCP can access your medical records from your previous provider. To take advantage of no copay or reduced copay for pharmaceuticals: Transfer all medication refills to a Kern Medical pharmacy. Allow 2-3 business days for the transfer to be completed. If your medication had an approved Prior Authorization on your previous plan, contact Member Services to ensure that the filling of your prescription will not be delayed. If you need help with transitioning or have questions about the plan or benefits, Member Services is always happy to assist you. Contact us Monday - Friday 8 am - 5 pm. (661) or 1 (855)

12 Kern Legacy Health Plan Network Plus Ph: (661) FAX: (661) Truxtun Ave, 1st Floor Bakersfield, CA Website: One Plan. Two options. Same customer service with a personal touch. A health plan your way.