The Harvard Pilgrim Primary ChoiceSM Plan COMMONWEALTH OF MASSACHUSETTS GROUP INSURANCE COMMISSION

Transcription

1 The Harvard Pilgrim Primary ChoiceSM Plan COMMONWEALTH OF MASSACHUSETTS GROUP INSURANCE COMMISSION

2 WHAT YOU NEED TO KNOW: Primary Choice SM Which providers and hospitals can I visit? You can use only providers (doctors and other medical professionals) and hospitals that belong to the Primary Choice network, except in a medical emergency. Do I need a primary care provider (PCP)? Yes. You must have your PCP provide your care (except in emergencies) and give you referrals for most kinds of specialty care for the plan to provide coverage for the service. Make sure that the PCP you choose has admitting privileges at a Primary Choice hospital. After you enroll, call Member Services to tell us who your PCP is. If you do not, we will assign a PCP to you upon enrollment. My family and I already have PCPs that we like. Can we continue to see them? Yes, if your PCPs are part of the Primary Choice network. To find out, use the Primary Choice provider directory at Make sure your PCPs have admitting privileges at Primary Choice hospitals. Do I need referrals to visit specialists? Yes, you need your PCP s referral for most visits to Primary Choice specialists. Please make sure your specialist has admitting privileges at and refers you to a Primary Choice hospital. You can get routine eye exams and most kinds of gynecological care without your PCP s referral, but you must see Primary Choice providers for these services. What about going to the hospital? If you need tests or surgery at a hospital, you must be sure that your PCP or specialist sends you to a Primary Choice hospital. The only time you don t need a referral to go to the hospital is in a medical emergency. Can I go to providers and hospitals that are not part of the Primary Choice network? No. Except in a medical emergency, if you go to a provider or hospital that is not part of the Primary Choice network, you will be responsible for paying all charges. What do I do in a medical emergency? In a medical emergency (e.g., heart attack, stroke, choking, loss of consciousness or seizures), call 911 or go to the nearest emergency room. If you are admitted to the hospital, someone needs to notify your PCP or Harvard Pilgrim within 48 hours or as soon as reasonably possible. Your attending physician may do this, or you can ask someone to do it for you. Do I have coverage when I m traveling? You have coverage for unexpected or unforeseen urgent care (e.g., earache, flu or sprain) and for medical emergencies when you re traveling outside the state where you live. Otherwise, you must receive care from Primary Choice providers and hospitals, (generally) coordinated by your PCP. Before you choose this plan... Except in an emergency, you can receive care only from Primary Choice providers and hospitals. Some providers and hospitals that belong to the Harvard Pilgrim/Independence Plan network do not belong to the Primary Choice network. If there are certain PCPs, specialists and hospitals that are important to you, you must make sure they participate in the Primary Choice network and that the PCPs and specialists have admitting privileges at Primary Choice hospitals. Your PCP or specialist must refer you to other Primary Choice providers and hospitals for the plan to provide coverage for the service. Otherwise you will be responsible for paying all charges.

3 Details about Primary Choice The Harvard Pilgrim Primary Choice SM Plan Choose this plan if... Do I need to select a primary care provider (PCP) and get referrals from my PCP to see specialists? Do I have an opportunity to save with lower-cost Tier 1 providers and hospitals? Which providers and hospitals can I visit? You want to save money with a lower monthly premium and you will be sure to use the plan s smaller provider and hospital network (except in medical emergencies). Yes Yes Only the providers and hospitals that participate in the Primary Choice network. This is a smaller network than the Independence Plan/Harvard Pilgrim network. Important: This is a limited network plan. Except in a medical emergency, you will have to pay for your care if you use doctors or hospitals that are not part of the Primary Choice plan. Office visit copayments PCP level copayment: $20 Specialist copayments: $30 or $60 Prescription drug copayments Who can enroll? Deductible: $100 per Member / $200 per Family, then $10, $30 or $65 (up to 30-day supply) $25, $75 or $165 (up to 90-day supply**) GIC enrollees (active employees, or retired and not eligible for Medicare) who live in Massachusetts, excluding Barnstable County, Martha s Vineyard and Nantucket. Retired municipal teachers in the GIC s RMT program or Elderly Governmental Retirees in the GIC s EGR program are not eligible. Please note that there is a very limited network in Berkshire County. If you live in that area please check whether your providers and hospitals participate. **For maintenance medications only. Please see the Summary of Benefits for other applicable cost-sharing amounts, including deductibles and coinsurance.

4 Tiered providers and hospitals Harvard Pilgrim placed its participating physicians and hospitals into one of two tiers, based on cost and quality performance. Using national quality benchmarks, as well as plan medical expense information, we placed participating hospitals and physician groups in Tier 1 or Tier 2. If a physician group didn t have sufficient data to rank, the affiliated doctors were placed into Tier 2. When you see participating providers in Tier 1, you ll pay less. Your cost sharing increases when you receive services from Tier 2 providers. Refer to your Harvard Pilgrim Schedule of Benefits to determine your plan s actual cost sharing. Are providers always in the same tier as the hospitals where they admit patients? No. Sometimes providers and hospitals are placed in different tiers. Be sure to confirm providers and hospitals tiers before you seek care. Will providers stay in the same tier? Providers tier assignments may change at any time. For example, if providers change practice affiliations, their tier assignments may change as well. Providers who work for more than one practice may be in more than one tier; what you pay will depend on the practice location you visit. Centered Care Harvard Pilgrim is working with the GIC and our provider groups to bring you better health care quality and a better patient experience through the Centered Care initiative. Visit org/gic to: Find out more about Centered Care Watch a short presentation about primary care providers Learn about preventive care Consider quality In both tiers, you ll find physicians from Harvard Pilgrim s honor roll, which recognizes local providers whose performances meet high-quality, best-in-class industry standards. This means that while all Honor Roll recipients are recognized for outstanding quality, some are more cost-efficient than others. That s why you ll find Honor Roll recipients in both tiers for cost and quality performance.

5 Nearly 100,000 state and municipal members rely on Harvard Pilgrim for health care coverage through the Group Insurance Commission (GIC). Why should we be your health plan too? Because you can count us in to give you... A plan with ways to save GIC members enrolled in Harvard Pilgrim s Primary Choice SM Plan can save on visits to specialists and hospital stays by choosing providers in lower-cost tiers. Outstanding service from a local health plan that s among the best in the country Harvard Pilgrim is recognized across the country for outstanding quality and customer service. Consistently among the nation s highestrated health plans,* Harvard Pilgrim Health Care has been rated 4.5 out of 5 for its private HMO/POS and PPO plans in NCQA s Private Health Insurance Plan Ratings Savings on products and services that can help you live a healthy lifestyle Get up to $200 fitness reimbursement per individual and up to $400 per family when you join Primary Choice. Questions? Visit us online at or give us a call please be sure to tell us you are enrolling through the GIC. Already a Harvard Pilgrim member? Call (888) Not yet a member? Call (800) For TTY service, call 711 Save with Primary Choice Primary Choice is a limited-network plan that may help you save money on your monthly premium compared to many of the other GIC health plan options. Before you sign up, be sure to check the Provider Directory or call us at one of the numbers under Questions? to see whether the PCPs, specialists and hospitals that are important to you participate in this plan. If not, would you change to Primary Choice doctors and hospitals? Remember, if you join Primary Choice you can use ONLY Primary Choice doctors and hospitals. * NCQA s Private Health Insurance Plan Ratings, NCQA s Private Health Insurance Plan Rankings, , HMO/POS/PPO.

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