Explorer Plan (HMO-POS) SunSaver Plan (HMO-POS)

Transcription

1 January 1, 2016 December 31, 2016 Explorer Plan SunSaver Plan SECTION I INTRODUCTION This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (feefor-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan such as and Florida Hospital SunSaver Plan. Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Florida Hospital Explorer Plan and covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Florida Hospital Explorer Plan and Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non- English language. For additional Y0089_EL4833FH Accepted Page 1 of 19

2 information, call us at (TDD/TTY relay: ). Things to Know About Florida Hospital Explorer Plan (HMO- POS) and Florida Hospital SunSaver Plan Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time, Saturday from 8:00 a.m. to 12:00 p.m. Eastern time. and Florida Hospital SunSaver Plan (HMO- POS) Phone Numbers and Website If you are a member of this plan, call tollfree (TDD/TTY relay: ). If you are not a member of this plan, call toll-free (TDD/TTY relay: ). Our website: myfhca.org Who can join? To join and Florida Hospital SunSaver Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Florida: Volusia, Flagler, Hardee, and Highlands. Which doctors, hospitals, and pharmacies can I use? (HMO- POS) and Florida Hospital SunSaver Plan have a network of doctors, hospitals, pharmacies, and other providers. For some services you can use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website, myfhca.org. Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, myfhca.org. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Y0089_EL4833FH Accepted Page 2 of 19

3 SUMMARY OF BENEFITS January 1, 2016 December 31, 2016 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-ofpocket costs for medical and hospital care. Your yearly limit(s) in this plan: $4,500 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. $87 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $2,900 for services you receive from in-network providers. $8,000 for services you receive from out-ofnetwork providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_EL4833FH Accepted Page 3 of 19

4 OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Not covered Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Ambulance 1 In-network: $195 copay In-network: $150 copay Chiropractic Care Dental Services 1 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $30 copay Preventive dental services: Cleaning: In-network: $0 copay Dental x-ray(s): In-network: $0 copay Fluoride treatment: In-network: $0 copay Oral exam: In-network: $0 copay Our plan pays up to $100 every year for preventive dental services from an in-network provider. Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): out of position): In-network: $20 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move In-network: $20 copay Out-of-network: 20% of the cost Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $20 copay Preventive dental services: Cleaning: In-network: $0 copay You are covered for up to 1 every year. Dental x-ray(s): In-network: $0 copay You are covered for up to 1 every year. Fluoride treatment: In-network: $0 copay Oral exam: In-network: $0 copay You are covered for up to 1 every year. Our plan pays up to $200 every year for preventive dental services from an in-network provider. Y0089_EL4833FH Accepted Page 4 of 19

5 OUTPATIENT CARE AND SERVICES Diabetes Supplies and Services 1 Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Doctor s Office Visits Diabetes monitoring supplies: In-network: 20% of the cost Diabetes self-management training: In-network: You pay nothing Therapeutic shoes or inserts: In-network: 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): In-network: $200 copay Diagnostic tests and procedures: In-network: $35 copay Lab services: In-network: You pay nothing Outpatient X-rays: In-network: $35 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: You pay nothing Primary care physician visit: In-network: You pay nothing Specialist visit: In-network: $30 copay. There is a limit Diabetes monitoring supplies: In-network: 20% of the cost Diabetes self-management training: In-network: You pay nothing Therapeutic shoes or inserts: In-network: 20% of the cost Continuous glucose monitoring: In-network: 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): In-network: $125 copay Diagnostic tests and procedures: In-network: You pay nothing Lab services: In-network: You pay nothing Outpatient X-rays: In-network: $15 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: You pay nothing Primary care physician visit: In-network: You pay nothing Specialist visit: In-network: $20 copay Y0089_EL4833FH Accepted Page 5 of 19

6 OUTPATIENT CARE AND SERVICES Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) Hearing Services to how much our plan will pay. In-network: 20% of the cost In-network: 20% of the cost $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: In-network: $35 copay Exam to diagnose and treat hearing and balance issues: In-network: $35 copay $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: Y0089_EL4833FH Accepted Page 6 of 19 In-network: $20 copay Out-of-network: 20% of the cost Exam to diagnose and treat hearing and balance issues: In-network: $15 copay Routine hearing exam: In-network: $15 copay. You are covered for up to 1 every year. Home Health Care 1 In-network: You pay nothing In-network: You pay nothing Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility

7 OUTPATIENT CARE AND SERVICES (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $191 copay per day for days 1 through 8 You pay nothing per day for days 9 through 90 Outpatient group therapy visit: In-network: $40 copay Outpatient individual therapy visit: In-network: $40 copay Outpatient Cardiac (heart) rehab services (for a maximum of 2 Rehabilitation 1 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $35 copay Occupational therapy visit: In-network: $30 copay (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: Out-of-network: 20% of the cost per stay Outpatient group therapy visit: In-network: $20 copay Outpatient individual therapy visit: In-network: $20 copay $125 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $20 copay Occupational therapy visit: Y0089_EL4833FH Accepted Page 7 of 19

8 OUTPATIENT CARE AND SERVICES Outpatient Substance Abuse 1 Outpatient Surgery 1 Physical therapy and speech and language therapy visit: In-network: $30 copay Group therapy visit: In-network: $50 copay Individual therapy visit: In-network: $50 copay Ambulatory surgical center: In-network: $195 copay Outpatient hospital: In-network: $195 copay In-network: $20 copay Physical therapy and speech and language therapy visit: In-network: $20 copay Group therapy visit: In-network: $35 copay Individual therapy visit: In-network: $35 copay Ambulatory surgical center: In-network: $85 copay Outpatient hospital: In-network: $85 copay Over-the-Counter Items Not Covered Please visit our website to see our list of covered over-the-counter items. Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: In-network: 20% of the cost Related medical supplies: In-network: 20% of the cost Prosthetic devices: In-network: 20% of the cost Related medical supplies: In-network: 20% of the cost Renal Dialysis In-network: 20% of the cost In-network: 20% of the cost Transportation Not covered Not covered Urgently Needed $35 copay $20 copay Y0089_EL4833FH Accepted Page 8 of 19

9 OUTPATIENT CARE AND SERVICES Services Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $30 copay Routine eye exam: In-network: $30 copay. You are covered for up to 1 every year. Contact lenses: In-network: You pay nothing. Eyeglasses (frames and lenses): In-network: You pay nothing. You are covered for up to 1 every year. Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing. Our plan pays up to $75 every year for eyeglasses (frames and lenses) from an in-network provider. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $20 copay Routine eye exam: In-network: $0 copay You are covered for up to 1 every year. Contact lenses: In-network: $0 copay Eyeglasses (frames and lenses): In-network: $0 copay Eyeglasses or contact lenses after cataract surgery: In-network: $0 copay Our plan pays up to $125 every year for eyeglasses (frames and lenses) from an in-network provider. PREVENTIVE CARE Preventive Care In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Y0089_EL4833FH Accepted Page 9 of 19

10 PREVENTIVE CARE Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (onetime) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (onetime) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. HOSPICE Hospice You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care 1 The copays for hospital and skilled nursing facility The copays for hospital and skilled nursing facility Y0089_EL4833FH Accepted Page 10 of 19

11 Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $200 copay per day for days 1 through 8 You pay nothing per day for days 9 through 90 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. In-network: You pay nothing per day for days 1 though 20 $156 copay per day for days 21 though 100 (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $125 copay per day for days 1 through 10. You pay nothing per day for days 11 through 90 Out-of-network: 20% of the cost per stay For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. In-network: $20 copay per day for days 1 though 100 Out-of-network: 20% of the cost per stay Prescription Drug Benefits Y0089_EL4833FH Accepted Page 11 of 19

12 How much do I pay? For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost Other Part B drugs 1 : In-network: 20% of the cost Initial Coverage You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing: Tier 1 (Preferred Generic): One-month supply: $2 Three-month supply: $6 Tier 2 (Generic): One-month supply: $5 copay Three-month supply: $15 copay Tier 3 (Preferred Brand): One-month supply: $45 copay Three-month supply: $135 copay Tier 4 (Non-Preferred Brand): One-month supply: $90 copay Three-month supply: $270 copay Tier 5 (Specialty Tier): One-month supply: 33% of the cost Three-month supply: Not offered Standard Mail Order Cost-Sharing: Tier 1 (Preferred Generic): Three-month supply: $0 Tier 2 (Generic): Three-month supply: $0 For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost Other Part B drugs 1 : In-network: 20% of the cost You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing: Tier 1 (Preferred Generic): One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): One-month supply: $2 copay Three-month supply: $6 copay Tier 3 (Preferred Brand): One-month supply: $45 copay Three-month supply: $135 copay Tier 4 (Non-Preferred Brand): One-month supply: $90 copay Three-month supply: $270 copay Tier 5 (Specialty Tier): One-month supply: 33% of the cost Three-month supply: Not offered Standard Mail Order Cost-Sharing: Tier 1 (Preferred Generic): Three-month supply: $0 Tier 2 (Generic): Three-month supply: $0 Y0089_EL4833FH Accepted Page 12 of 19

13 Coverage Gap Tier 3 (Preferred Brand): Three-month supply: $90 copay Tier 4 (Non-Preferred Brand): Three-month supply: $180 copay If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing: Tier 1 (Preferred Generic): Drugs Covered: All One-month supply: $2 Three-month supply: $6 Standard Mail Order Cost-Sharing: Tier 3 (Preferred Brand): Three-month supply: $90 copay Tier 4 (Non-Preferred Brand): Three-month supply: $180 copay If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing: Tier 1 (Preferred Generic): Drugs Covered: All One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): Drugs Covered: All Y0089_EL4833FH Accepted Page 13 of 19

14 Catastrophic Coverage Tier 1 (Preferred Generic): Drugs Covered: All Three-month supply: $0 After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the cost, or $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. One-month supply: $2 copay Three-month supply: $6 copay Standard Mail Order Cost-Sharing: Tier 1 (Preferred Generic): Drugs Covered: All Three-month supply: $0 Tier 2 (Generic): Drugs Covered: All Three-month supply: $0 After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the cost, or $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. Y0089_EL4833FH Accepted Page 14 of 19

15 Obtaining Covered Medical Care How do I get medical and behavioral health care? The way you obtain routine medical care will depend on the type of plan you have. General provisions HMO Plans: Generally speaking, HMO plans require you to see participating providers for covered services, except for urgent care, emergency care and dialysis outside the service area. All other out-of-network services must be authorized in advance by Health First Health Plans (HFHP) or they will not be covered. It is important to remember this provision, especially when you are outside our service area for any reason. If you are enrolled in an HMO plan, it is very important that you know whether or not your provider participates with HFHP so you don t incur charges for services that may not be covered. Be sure to check your Summary of Benefits, Evidence of Coverage, visit our website or contact us to determine if services are covered. HMO-POS Plans: You may see non-participating providers but your costs may be higher than if you receive the services innetwork from participating providers. These types of plans offer more choices in the delivery of health care, but typically include higher premiums and out-of-pocket costs. Be sure to check your Summary of Benefits, Evidence of Coverage, visit our website or contact us to determine if services are covered. Regardless of which general type of plan you have, benefits and cost-sharing requirements will vary depending on the plan you re enrolled in. Primary care To access primary care, simply contact your doctor to make an appointment. For after-hours care, you can also call your doctor s answering service 24 hours a day for instructions. You may be directed to an urgent care center or to make an appointment when your physician s office is open. You may also be directed to an emergency room, if you think you have a medical emergency. Emergency care If you have a medical emergency, have someone take you to the closest emergency room. If you cannot get to the emergency room safely and quickly, call 911. Be sure to show your HFHP member ID card. If you are admitted to the hospital or need help coordinating your care after you are stabilized, have someone contact HFHP and your local doctor for assistance. We cover emergency medical care anywhere in the world and will help arrange for your transfer home if necessary. Urgently-needed care If you need care after hours or urgently, but it is not an emergency, participating urgent care centers are open evenings and weekends. They are listed in your Provider Directory and on our website. Avoiding unnecessary trips to a hospital emergency room can save you time and money. You may also contact Nurse24 at if you have a question that you would like answered by a health care professional. This toll-free line is available 24 hours per day, 7 days per week. If you are outside the service area, you are covered for unforeseen illnesses or injuries that need to be treated before you return. Simply locate an urgent care clinic or other physician for the initial treatment and contact your local doctor to obtain any necessary follow-up services. If at all possible, try to locate a provider that is part of our contracted national provider network, as we have negotiated preferred pricing through this network for out-of-area care. You can locate one of these providers by contacting us for assistance. Hospital care If you need to be hospitalized and it s not an emergency, your doctor must get authorization from us first and coordinate your admission. Authorizations may be required for some outpatient services performed at a hospital, but if you see a Y0089_EL4833FH Accepted Page 15 of 19

16 participating doctor, he or she will know if that s necessary and can take care of it for you. You never need authorization for emergency care at any hospital. If you are admitted to a non-participating hospital as part of your emergency care, please have someone contact us at so we can help coordinate your care as soon as possible. Mental (behavioral) health services Mental health services can be accessed directly without a physician referral as with other specialty care. If you are enrolled in an HMO plan, you can arrange for the appropriate services by calling Magellan Health Services directly at HFHP (4347); TTY/TDD users should call or visiting their website at A mental health professional will assist you with obtaining the help you need. HMO-POS members can access the provider of their choice and applicable cost-sharing amounts will apply. When do I need a referral or authorization? To make it easy for you to obtain medical care, HFHP does not require members to get a referral to see participating specialists for covered services. However, some specialists may require you to be referred by your primary doctor to ensure your care is coordinated properly. To locate a participating provider for specialty care, please see your Provider Directory or contact us for assistance. While most covered medical care can be obtained without our involvement, some services require prior authorization by our Medical Management staff to ensure the right care is provided in the right setting. Your physician will assist you by contacting us for services that require prior authorization. Also, remember that referrals and prior-authorized services are still subject to plan exclusions and limitations. Check our current Authorization List to see if approval is required in advance and to ensure you don t incur any unexpected expenses for services that may not be covered. You can get the Authorization List from our website or by calling us. Certain services require prior authorization to be covered and POS members obtaining care from non-participating providers are responsible to ensure authorization is obtained. A few examples that require prior authorization include MRI, PET, CT scans and nuclear cardiology studies, but other services require authorization and the list is subject to change. If you are using a provider who does not participate in the Health First Health Plans network, including our contracted national provider network, please be sure you discuss the authorization process with your provider, notify HFHP and make sure the service is approved before receiving it. You are responsible for notifying your non-participating physician that authorization is required for these procedures. If your physician has any questions or needs instructions on how to obtain prior authorization, he or she may contact our Customer Service department for additional information. What if I need a second opinion? For HMO and POS members, a second medical opinion related to the need for surgery or a major non-surgical diagnosis/therapeutic procedure with a HFHP participating provider does not require prior authorization. In network office cost share would apply. For HMO members, a second opinion with an out of network provider requires prior authorization. Please contact Health First Health Plans to submit a prior authorization request. For POS members, the out of network office cost share will apply if prior authorization is not obtained prior to seeing an out of network provider. All third opinions require prior authorization. Health First Health Plans has a limit of three opinions per medical condition per calendar year. Y0089_EL4833FH Accepted Page 16 of 19

17 Decision making at HFHP HFHP assures providers, practitioners and members that all decisions involving HFHP coverage are based on the 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. HFHP works to prevent inappropriate decision making by regularly monitoring all medical claims and request for care. We are committed to providing you access to quality care. Health management When it comes to your health, sometimes you need more information and a little support making a decision. Sometimes you just need someone to talk to one-on-one about how to live a healthier life in body and mind. Health First Health Plans is committed to providing members a complete managed care network which delivers the highest quality, most cost effective care possible. The Health Plan looks at the inpatient and ambulatory care (including: pre-service, concurrent, or post-service authorization) using utilization review criteria to make sure this is appropriate and timely. Health First Health Plans considers multiple factors when making coverage decisions, including member benefit contracts, laws and regulations, and the medical necessity of a requested item or service regarding the member s unique clinical situation. The Health Plan involves appropriate professionals in the development, adoption, and review of criteria and medical coverage policies. When available, Medical Policies will be used to make medical necessity decisions. If there is no Medical Policy, the following evidence-based resources will be applied by appropriate reviewers: Centers for Medicare & Medicaid Services (CMS), Milliman Care Guidelines, Hayes Technology Assessments, Peer-reviewed published medical literature, Clinical guidelines from nationally recognized authorities and FDA approval status (approval does not imply medical necessity). The Health Plan uses the approved new medical technologies or new uses of existing technologies after a complete review of the literature and recommendations from our specialists. Health First Health Plans measures and reviews professional and member satisfaction with Utilization Management services and takes action on identified opportunities for improvement. Health Coaches When it comes to your health, sometimes you need more information and a little support making a decision. Sometimes you just need someone to talk to one-on-one about how to live a healthier life in body and mind. HFHP offers access to a personal Health Coach, at no additional cost by phone, or chat 24 hours a day, 7 days a week. A Health Coach is a trained, healthcare professional (a nurse, dietician or respiratory therapist) who can provide you with oneon-one information on a variety of health issues, help you monitor your health needs and help you work more closely with your doctor. Health Coaches can also help you identify incremental goals to sustain long-term behavior changes in the following areas: Improve your diet You can: Feel and look better Manage stress Gain confidence Reach a healthy weight Have more energy Improve your fitness level Talk with a Health Coach anytime, day or night for information about enrolling or if you have any questions. Just call to speak with a knowledgeable and caring healthcare professional. Once you have signed up for the program, you will get a Health Coaching workbook which includes goal setting resources that promote healthy behavior changes. Receive personalized monthly check-in calls. Also, you can or call your coach any other time. Use online services featuring 24/7 access to health and decision support tools by logging into our website at Y0089_EL4833FH Accepted Page 17 of 19

18 myfhca.org/myportal. Other online health management services There are many other health management services you should take advantage of by logging into our website at myfhca.org/myportal. This information is available 24/7 and is designed to empower you to be more accountable for your own health. Through our Healthy Living program (online module), you can get information about disease conditions and help meeting wellness goals you might have such as smoking cessation. Disease Management/Chronic Care Access your up-to-date health information by logging into our website at myfhca.org/myportal. You can take the Health Assessment to learn about your own health risks and what you can do to lower them. You can also access in-depth information on more than 1,900 health topics including medical tests and medications. There are also many videos and DVDs available to you, at no charge, on conditions such as breast cancer, prostate cancer, back pain and osteoporosis. Need someone to talk to about a health issue? Call a healthcare professional at for caring support from someone who will take the time to listen to your concerns and answer your questions. They are ready to assist you with general health information, and support on managing a chronic illness such as: Diabetes Heart disease Congestive heart failure Asthma Coronary artery disease COPD Complex Case Management For our members coping with complex or serious medical conditions, a life-changing accident or experiencing frustration or roadblocks in trying to get the care you feel you need, HFHP offers a personal RN-Case Manager to work one-on-one with you, your family and/or caregivers to help navigate the sometimes confusing world of healthcare. These highly trained and professional nurses work closely with your medical team to make sure you understand your condition, the best treatment options available and how to connect with any support you may need during this challenging time in your life. We have highly skilled social workers available to assist with community resources or financial problem solving as well. Members undergoing transplants, cancer treatments or any other complex medical condition are appropriate for this service. Please contact Customer Service to access our Complex Case Management services. Additional Management Programs Physician Home Visiting Program You may be referred to a Physician Home Visiting Program if you are unable to get to the doctor s office due to illness. If you meet requirements for this program, you have access to a doctor or nurse practitioner 24 hours per day, 7 days per week. These health care professionals may come to your home and are able to provide medical care, many times preventing emergency room visits and admissions to the hospital. These professionals work closely with you and your family or caregivers, doctors and our Health Plans staff to help keep you in the best possible health and teach you how to cope with your illness. Transition of Care Program Some medical conditions are known to cause frequent trips to the hospital. Members who are hospitalized with one of these conditions may qualify for the Transition of Care Program. An RN from the Case Management team reaches out to these members within the first week after discharge from the hospital to access and manage their immediate care needs, or to see if extra care from a doctor in the home might help them to understand their medicines, discharge instructions and illness. Some of the illnesses that would qualify someone for this program include, but are not limited to, congestive heart failure, heart disease and diabetes. Y0089_EL4833FH Accepted Page 18 of 19

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