|
|
Frequently Asked Questions
Have a question? The answer may be here. Scroll down to find the question and answer you need. These FAQs are updated as "hot" issues are identified.
- What is Patient Choice?
- How is Patient Choice different from other health plans and preferred provider networks?
- How does the plan work?
- What is a Care System?
- What is a cost group and what do the dollar signs mean?
- Are the Care Systems in cost group III better than those in cost group I?
- Why do Care System costs vary?
- Can the cost group a Care System falls into change from year to year?
- What is in- and out-of-network?
- Can I change Care Systems during the year?
- Can my clinic participate in different Care Systems?
- How can I determine if a health care provider is affiliated with my Care System?
- Do I need to verify that a provider listed in the directory is participating in my Care System before my visit?
- Can I directly access care from a specialist?
- Can I visit a chiropractor or acupuncturist?
- What if I need medical care while I'm out of town?
- How can I find out more about special programs and initiatives available through my selected Care System?
What is Patient Choice?
Patient Choice is an innovative patient-focused health care program that gives individuals the ability to choose the providers that will best meet their specific health care needs and budgets.
How is Patient Choice different from other health plans and preferred provider networks?
The Patient Choice program features a unique tiered network that differentiates health care providers based on a variety of performance measures. Individuals receive user-friendly information to help them compare the cost, quality and service of health care providers so they can make informed choices about their medical care.
How does the plan work?
Enrolling in a plan that uses the Patient Choice network consists of completing the following simple steps:
- You and each of your family members select a custom network of providers and facilities called a “Care System.” Each family member is free to select a different Care System.
Your Care System selection is the key to receiving in-network coverage for your care—the highest
level of benefits available through your employer-sponsored plan. Services delivered by providers
affiliated with their selected Care System are considered in-network services with eligible services covered at the in-network benefit level.
Your Care System selection may also determine the amount you contribute towards the cost of your coverage. In the Patient Choice network Care Systems are tiered into low, medium and high cost groups. If you choose a Care System in a lower cost group, the cost of your coverage will be less than if you choose a Care System in a higher cost group.
Review information in the directory and the Care System Comparison Guide to learn more about your Care System choices. You can use the information to consider each Care System’s special expertise in treating certain conditions, cost, patient satisfaction results and whether it has received an “Excellence in Quality” award.
- In most cases, each family member will also choose a primary care clinic within their selected Care System. Your primary clinic is the clinic you’ll visit for most of your general health care needs such as checkups and preventive care.
- Once you have made your final choices, you enroll in the plan. To complete enrollment you’ll need to know the following items for each family member’s selection: Care System name, primary care clinic name, and primary clinic number. Note: Primary clinic numbers can be found in online directory.
- After enrolling in the plan, family members obtain services from the doctors, hospitals and other health care providers affiliated with their selected Care System to be eligible for in-network benefits.
What is a Care System?
A Care System is a custom network within the Patient Choice network. Each Care System includes primary care physicians, specialists, hospitals and other health care professionals and facilities that work together to provide a broad range of services. Each system determines which providers and approach to care will best serve their patients.
What is a cost group and what do the dollar signs mean?
Care Systems participating in the Patient Choice program determine their own pricing. Analyzing the price Care Systems set, and factoring in each System’s approach to managing their patients’ care, Patient Choice compares Care Systems and tiers them into low, medium high cost groups.
Cost groups are used to help you understand the differences in Care System costs. They can also indicate a premium or contribution level—the amount you’ll contribute to the cost of your coverage.
If your employer charges different amounts depending on the Care System’s cost group, your Care System choice will affect the amount you pay for your coverage—Care Systems that fall into a lower cost group will cost you less than those in higher cost groups.
Are the Care Systems in cost group III better than those in cost group I?
No. Cost groups do not signify higher or lower quality. They are simply used to identify how Care System costs compare to one another. In the Patient Choice program, providers that deliver quality care and make the most effective use of resources can pass along lower costs to you and your employer.
Why do Care System costs vary?
Care System costs can vary for several reasons. Operating expenses, facility costs, supplies are just a few examples of factors that can affect costs. Also consider Care Systems that do the best job for their patients such as keeping them healthy so they don’t need to enter the hospital, avoiding complications when hospitalizations do occur and utilizing the most effective resources results in better quality care at a lower total cost.
Can the cost group a Care System falls into change from year to year?
Yes. Each year Care Systems submit their prices to Patient Choice. Patient Choice analyzes each Care System’s price, combined with their ability to efficiently manage patient care. Care Systems are then compared to one another and arranged into cost groups. Depending on a Care System’s performance and their willingness to price themselves competitively to consumers, they may change cost groups.
What are in- and out-of-network services?
Services furnished by the health care providers and facilities affiliated with your selected Care System are considered “in-network” services. Eligible services will be covered at the in-network benefit level—the highest level available through your employer’s plan.
Services furnished by health care providers and facilities that are NOT affiliated with your selected Care System are considered “out-of-network” services. Eligible services will be covered at the out-of-network benefit level. Your out-of-pocket costs will be higher for out-of-network services.
Can I change Care Systems during the year?
Yes. Flexibility is an important part of the Patient Choice program. If you want to obtain care at a clinic in a different Care System, simply call Customer Service to change your selections prior to receiving services. You can change your selections as often as once a month.
If you request a change by the 20th of the month, your new selection will be effective the first day of the following month. For example, if you request a change on or before March 20, your new selection will be effective April 1. If you request a change March 21-31, your selection will be effective May 1.
Can my clinic participate in different Care Systems?
Primary clinics participate in only one Care System. Specialty clinics may participate in more than one Care System.
How can I determine if a health care provider is affiliated with my Care System?
The Patient Choice online directory contains information about each Care System and its affiliated providers, hospitals and other care facilities. You can also find information by calling Customer Service at 877-390-7632.
Do I need to verify that a provider listed in the directory is participating in my Care System before my visit?
Yes. The Patient Choice Care System network continually evolves. To maximize the benefits available in your plan, you should always verify that a provider participates in the Patient Choice network and continues to serve your Care System prior to receiving services.
You can find out if your provider participates in the network by using the online directory. If you do not have access to the Internet, you should contact Customer Service at 877-390-7632.
Can I directly access care from a specialist?
Yes. You may directly access care from any specialist that is affiliated with your selected Care System.
Can I visit a chiropractor or acupuncturist?
Patient Choice members can directly access services from chiropractors and acupuncturists participating in the Patient Choice Care System network. The benefits available and the type of conditions covered, depend on your employer’s plan. See your employer’s enrollment materials or your Summary Plan Description document for more information.
What if I need medical care while I'm out of town?
Patient Choice provides coverage for emergency care, even when you're traveling to areas where there are no Patient Choice providers. If you are admitted to a hospital outside the Patient Choice service area, you should notify Customer Service once your condition has stabilized.
How can I find out more about special programs and initiatives available through my selected Care System?
In addition to the information available on the Patient Choice Web site, many of the Care Systems have their own Web sites. The information available on the sites varies by Care System. Some of the sites provide: general health and wellness information, condition-specific information, tips for managing chronic health issues, treatment options, procedure preparation instructions, class or seminar listings, contact information and more. Click here to view the list of Care System Web sites.
|
|
