HMO 101 Navigating Your Health Plan

1. HMO 101Navigating Your Health Plan UCSF HR/Benefits Health Care Facilitator Program 2007

2. 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

3. 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

4. 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

5. 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 Net PacifiCare (Blue Cross Plus: In Network functions like an HMO)

6. 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)

7. HMO: Open Panel

8. 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

9. Closed Panel HMO • All care is provided by employees of the HMO • UC-sponsored closed HMO’s include: • Kaiser Permanente

10. 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

11. HMO: Closed Panel

12. Advantages of Selecting an HMO • Low monthly premiums • Low co-payments • No deductibles or co-insurance • No claim forms • PCP coordinates your care

13. 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

14. Access to Services & Covered Benefits Services must be part of your plan benefits and be considered medically necessary

15. 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)

16. 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

17. 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”

18. 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

19. 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/

20. 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

21. Prescription Drug Co-Pays 2007

22. 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

23. Problem Solving What to do if you have problems How to be proactive and self-sufficient How to get assistance What you can expect

24. 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

25. 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

26. 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”

27. 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

28. 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

29. 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

30. 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/

31. 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

32. 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

33. 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

34. 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, sforstat@hr.ucsf.edu • Jason Neft, Assistant HCF, 476-5269, jneft@hr.ucsf.edu

35. Local Resources • Brown and Toland Medical Group (BTMG) • 553-6748 • customerservice@btmg.com • 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

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