Health Maintenance Organization (HMO) Plan
How to Use the HMO Plans
- Primary Care Physician (PCP)
- Speciality Care
- Pre-Authorization
- Care Received Outside the Service Area
- Urgent Care
- Emergency Care
- Continuation of Care
- Claims for Non-Network Providers
- Out-of-Pocket Maximums
- Coordination of Benefits
Primary Care Physicians only apply to members enrolled in Mercy Health Plans in the South Central and Southwest regions.
Your medical care must be directed by your Primary Care Physician (PCP) or “gatekeeper.” He/she determines treatment and provides referrals to specialists if necessary. You and your dependents may choose different PCPs from a listing of network providers supplied by the HMO. Family or general practitioners, internists or pediatricians can be selected as a PCP. You may change PCPs during the year.
If you fail to select a PCP, you have coverage for emergencies only until one is selected or Mercy assigns one for you. It is your responsibility to make sure the PCP is accepting new patients.
Note: If your PCP or Specialist withdraws from your medical plan, you are required to choose another network physician. You may not change plans at this time.
If you need ongoing care from a specialist and the medical plan requires referrals, the plan must have a procedure in place to allow a standing referral to that specialist. Treatment plans must be pre-approved by your HMO and may be limited to a specific number of visits or period of time.
If specialty care cannot be provided by a network provider, services may be obtained through a non-network provider. To receive network benefits from a non-network provider, authorization must be obtained in advance from your HMO. Contact your HMO for the proper procedure in obtaining care.
To enroll in an HMO, you must live or work in a county where the HMO is available. You may only enroll in a plan where you work if it is not available where you live.
Pre-authorization must be obtained by your HMO provider. Verify the approval from your plan. For example, if you are being admitted to the hospital, your physician must obtain pre-approval.
Care Received Outside the Service Area
Services outside of the network are not covered except in case of emergency care. However, if services cannot be provided from your HMO network of providers, you may contact your HMO for the proper procedure in obtaining care outside of the network. You must obtain approval from the HMO prior to seeking care. If approval is not obtained, charges are not covered except for emergency care.
Contact your HMO for the proper procedure in obtaining care. If procedure is not followed, charges are not covered.
Emergency care is any emergency medical condition leading a prudent layperson to seek immediate medical attention. This normally means the sudden onset of a health condition that manifests itself by acute symptoms and severity (including severe pain). Notify your HMO within 48 hours or as soon as possible after seeking care.
Examples of medical emergencies include, but are not limited to:
- Conditions placing a person’s health in significant jeopardy.
- Serious impairment to a bodily function.
Serious dysfunction of any bodily organ or part. - Inadequately controlled pain.
- Situations when the health of a pregnant woman or her unborn child are threatened.
State law provides that contracts between the medical plans and their providers include provisions for continuation of care for a period of up to 90 days. If a provider terminates or is terminated from the network and the continuation of care is medically necessary (i.e. disability, pregnancy, or life-threatening illness) the medical plan may authorize continued care from the terminated provider. You are responsible for applicable network copayment amounts. Contact your medical plan for authorization.
Claims for Non-Network Providers
Contact the appropriate plan to find:
- How, when and where to obtain claim forms, if required.
- The requirements for providing notice of claim and proof of loss. Claims shall not be invalidated or reduced if it was not reasonably possible to give notice within the specified time.
For non-network services, claims must be filed within 12 months of the date of service.
Network out-of-pocket maximums are limited to no more than 50% of the cost of providing a single service. Copayments are limited to no more than 20% of the cost of providing basic health care services for the total benefit period. In addition, copayments may not exceed 200% of the total annual premium.
Participating providers may change during the year. It is your responsibility to contact the medical plan to verify provider participation.
Benefits payable from MCHCP medical plans are subject to coordination of benefits. MCHCP medical plans work with the various group plans to make sure each pays what it should up to the total amount of medical allowable expenses. Through coordination of benefits, the cost of health care is managed by avoiding two payments for the same charge. (This provision does not apply to individual policies you may own.)
Under coordination of benefits, one plan is designated as “primary” (which means it pays first) and the other is designated as “secondary” (which means it pays up to any covered expenses that are not paid by the primary plan). In some instances you may also be eligible for benefits under a third plan.
It is likely your medical plan will require you to complete a questionnaire asking if you or your dependents have other insurance coverage. If you have other coverage, your plan will ask for the name of the company. This verifies how benefits are coordinated and must be answered before claims are paid.