2010_HMO_Benefits_PowerPoint_Presentation by shimeiyan


Real world practical solutions designed with you in mind
2010 Benefits Overview HMO Plan 10

The content provided in this presentation is for informational purposes only. For information regarding specific policy information, including regulations, limitations and exclusions, refer to your contract and/or benefit booklet.

Overview of Health Products
HMO Plan 10

Health Plan Terminology
• PCP – Primary Care Physician
– Family Practice, General Practice, Internal Medicine or Peditrician

• Copayments (copays) – a set amount member pays for covered services • Annual out-of-pocket (OOP) maximum (max) – the maximum a member pays out-of-pocket in any benefit year
– BlueCare HMO – max includes all applicable health-related copays and RX copays


Office Visits
Family Physician/PCP $20

Direct Access to HMO Specialists


Any services received at doctors office will apply to copay.

Lab In Network – Quest $0

Lab is paid at 100% by using Quest. You can make appointments online!!! www.questdiagnostics.com Cannot leave HMO Network except in case of Emergency.

HMO (Health Options)


Preventative Health
In addition to the $500 Adult Wellness Benefit


Based on doctor’s recommendation.
One Routine Health Assessment per Year.

Adult Wellness

$20 – PCP $35 – OB/GYN

Adult Wellness Benefit

Included in the See 2009 Clinical Annual Routine Preventive Care Health Guidelines on next slide. Assessment


2009 Clinical Preventive Care Guidelines – Child Preventive Schedule


2009 Clinical Preventive Care Guidelines – Child Immunizations


2009 Clinical Preventive Care Guidelines – Adult Preventive Schedule


2009 Clinical Preventive Care Guidelines – Adult Preventive Schedule


Hospital Services - Inpatient
Inpatient In-Network $150 Copay per Day up to a Maximum of $750 To determine tier levels or participation, go to the Online Provider Directory www.bcbsfl.com Any services received by a Provider while in the hospital.

Provider Services while Inpatient In Network



Hospital Services - Outpatient
Outpatient In-Network Hospital $200 To determine tier levels or participation, go to the Online Provider Directory www.bcbsfl.com

Provider Services while Outpatient In Network

Any services received by a Provider $0


Out of Pocket Maximum
In Network
Per Person/Family


The maximum a members pays out of pocket in a benefit year. All of the following is applied to Max Out of Pocket: All Copays


Mandatory Generic
30 Day Supply


Mail Order
90 Day Supply


If a Brand Name RX is purchased when a Generic RX is available and the Physician has not indicated that a Brand Name RX is medically necessary, member will be required to pay the difference between the cost of the Brand Name and Generic RX in addition to the RX copay


Diabetic Supplies - Medical
• Covered Under Medical When Physician That Specializes in the Treatment of Diabetes Certifies Services are Medically Necessary
– – – – Self Management Training and Educational Services Nutritional Counseling provided by a Licensed Dietitian Trimming of toenails, corns, calluses Therapeutic Shoes including Inserts and/or Modifications for the treatment of severe Diabetic Foot Disease – Insulin Pump/Supplies (Durable Medical Equipment)


Diabetic Supplies - Pharmacy
• • • • • • Insulin Syringes and needles for injecting Insulin Blood Glucose Testing Strips and Tablets Lancets Glucose Monitor Acetone Test Tablets


Want to get the most out of your next doctor's visit?
The more you tell your doctor about your health concerns, the better he or she can prevent, diagnose, or treat any problems. Follow these tips to get the most from each doctor visit. Preparing for your doctor's visit A little preparation can go a long way, saving you time and money. •Be sure to check our online provider directory to see if your doctor participates in our network. Your cost will be lowest when you use a participating health care provider. •Write down your concerns and questions before your visit, and bring them with you. •Bring paper and pen to take notes. •Ask a family member or friend to come along. They can help you ask questions and understand the answers. What Your Doctor Needs to Know Be sure you cover these topics: •Any health concerns you have–even sensitive subjects •Your symptoms, including when they began, how often they occur, how long they last, and whether they're getting worse •Services or tests other doctors have performed for you •All medications and supplements you take; bring a list or the actual products •Your family's medical history •Let your doctor know before your visit what language you prefer to speak or if you need an interpreter. What You Need to Know Before you leave the doctor's office, you may want to ask these questions: •What is my condition, and what caused it? •Which medications or other treatments do you recommend? How will they help? •Will there be any side effects? •Can lifestyle measures help my condition? •Should I avoid certain medicines, activities, or foods? •What kind of tests do I need–and why? •How soon will test results be available, and how will I get them? If you don't understand an answer or feel concerned about it, speak up! 16

When you need to see a doctor right away…
For non-emergency assistance—when you can’t get in to see your family doctor or don’t want to wait hours in the emergency room—urgent care centers are designed to provide prompt, quality service and help you save up to 50% on your out-of-pocket costs. • Urgent care centers are staffed with qualified doctors and nurses that can handle medical problems like cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal bites, sprains and even immunizations. • Most urgent care centers offer: Quality care and prompt service • Shorter wait times—compared to an emergency room • Weekend and after-hours care • Service without an appointment • Convenient locations • Check our online provider directory to find participating urgent care centers located near you. Keep the names and addresses in a convenient place should you need them in a hurry. • Serious injuries and emergencies • If you have a serious injury or require immediate attention due to shortness of breath, severe abdominal or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other emergency conditions, call 911 or visit the nearest hospital. • Be sure to contact your family doctor so that follow-up care can be scheduled, if necessary. • Help is a phone call away • If you have questions about a health condition or when to visit an urgent care center, you can speak to a Health coach by calling 1-877-789-2583. 17

Know about generics and how to get them…
One of the easiest ways to save money is to use the generic version of a prescribed brand-name drug when one is available. Your cost will be lower without sacrificing quality. So if you are starting a new medicine or refilling one, you may want to talk to your doctor, or have your pharmacist talk with your doctor, about whether a generic is available and right for you. • Check out this comparison chart and find generics using our online pharmacy tool. • Over-the-Counter options can lower your costs • Looking for ways to save money on medicine? There are other ways of filling the medicine cabinet without depleting your pocketbook. The key? Look for nonprescription, over-the-counter (OTC) medication. • Check with your doctor. An OTC may work for you. • OTC medication is medicine that can be sold without a prescription and is found on the shelves of stores like other packaged products. Many OTC medications are just as effective as prescription drugs. In fact, many OTC drugs were once available only with a prescription. These include popular pain relievers and allergy medications as well as drugs that fight ulcers, help you quit smoking, and more. Your doctor can tell you if an OTC medication can replace one of your prescriptions.


How to save on your next scan
How to save on your next scan • Not all imaging providers charge the same for their services. For example, an independent imaging center may charge less than a hospital. To help you reduce your out-of-pocket costs, it pays to do a little legwork. • Here are some ways to make the most of your benefits and lower your costs: • Discuss your imaging options with your doctor. Are there other ways to diagnose your condition that are just as effective? • If your doctor recommends a CAT scan, PET scan, MRI, MRA or nuclear cardiology, ask where it will be performed. You’ll have lower out-of-pocket costs if you use providers and facilities that participate in your plan’s network. • To save even more money, ask your doctor if your test can be done at an in-network Independent Diagnostic Testing Facility (IDTF). Services at an IDTF generally cost less than the same services done in an outpatient hospital setting. • Use our online provider directory or call the number on your ID card to verify whether or not the providers and facilities participate in your plan’s network. • Ask your doctor to request a pre-service review for these procedures. That way, you’ll always know up front whether the service is a covered benefit. Please be aware that you may be responsible for the cost of procedures you receive that are not considered medically necessary.


Go to http://www.bcbsfl.com/HealthySavings/surgery/doctorSaysSurgery.html for additional information on healthy savings.

• • Where can I go to get information about a claim?
– – Visit www.bcbsfl.com and go to Claims under the My Benefits menu section to view and print details of your claims. Under the BlueCard Program, if the physician or provider is participating in the Blue Cross and Blue Shield network in that state, they will reimburse the physician or provider for the services you receive and them submit claim to BCBSF for reimbursement. If you should receive a bill from the physician or provider, please contact Customer Service at 800-255-4908 for assistance. Member Responsibility is the out-of-pocket portion of a claim that a member is expected to pay. For example, deductibles, copayments, and non-covered services are Member Responsibility. When you log onto MyBlueService, you can email us a question concerning your claim by selecting Ask a Question about this Claim at the bottom of the Claim Status Detail page. You will receive a reply in the Message Center or you may call us at 800-255-4908. Not if you choose a provider from within your plan provider network. Your provider should process all claim submission paperwork on your behalf. If you choose a provider outside the network, you may have to file claims for reimbursement. Select Claims Statements under the My Benefits menu in MyBlueService. These are located on your Claims Details pages. Select Claims under the My Benefits menu and locate the specific claim you are looking for. An Explanation of Benefits (EOB) is a detailed statement that explains how we processed a medical claim based on your benefits plan. It shows how much was paid by your insurance plan, any out-of-pocket expenses that are your responsibility, and accumulation of deductibles. Depending on your plan, you may or may not receive Explanation of Benefits statements. A Member Health Statement is a detailed reference of finalized health and pharmacy claims activities for the preceding 28-days. This statement allows members to track claims and reconcile provider balances and can be used as documentation for FSA, HRA and HSA accounts.

When I receive services outside the State of Florida, who submits the claim to BCBSF?


What makes up Member Responsibility?


What if I have a question about a claim?


Do I have to submit claims?

• •

Where can I find my Member Health statement?
– –

Where can I find my Explanation of Benefits statements?


What is an Explanation of Benefits statement?


What is a Member Health statement?


Things To Remember

Save Money
• • • • • Use HMO (Health Option) doctors Use Quest Laboratories Stay in network using Online Provider Directory Provide doctor and pharmacy your ID card Log on to MyBlueService to view claims, benefit information, order new ID Cards and Member Handbooks • Call Customer Service when you have questions


To top