HMO 101

Navigating Your Health Plan

UCSF HR/BenefitsHealth Care Facilitator Program

2007

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

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

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

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 NetPacifiCare(Blue Cross Plus: In Network functions like

an HMO)

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)

HMO: Open PanelHealth Net PacifiCare

(Blue Cross Plus In-Network)

Primary Care Providers

Medical Group ABrown & Toland

Medical Group BMarin IPA

SpecialistsHospitals

LabsPrimary Care

ProvidersSpecialists

HospitalsLabs

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

Closed Panel HMO All care is provided by employees of the

HMO

UC-sponsored closed HMO’s include: Kaiser Permanente

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

HMO: Closed Panel

Kaiser

Kaiser Medical Group, San FranciscoPCPs

SpecialistsHospitals

Labs

Advantages of Selecting an HMO Low monthly premiums

Low co-payments

No deductibles or co-insurance No claim forms

PCP coordinates your care

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

Access to Services & Covered Benefits

Services must be part of your plan benefits and be considered

medically necessary

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)

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

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”

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

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/

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

Prescription Drug Co-Pays 2007

Rx Kaiser Health Net PacifiCareBC Plus

In-Network

Retail30 Day Supply

Generic - $10Brand - $20(Up to 100day supply)Non-Formulary-does not apply

Generic - $10Brand - $20Non-Formulary-$35

Generic - $10Brand - $20Non-Formulary - $35

Generic - $15Brand - $25Non-Formulary-$40

Mail Order 90 Day Supply

Can be arranged

Generic - $20Brand - $40Non-Formulary - $70

Generic - $20Brand - $40Non-Formulary - $70

Generic - $30Brand - $50Non-Formulary - $80

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

Problem SolvingWhat to do if you have problemsHow to be proactive and self-sufficientHow to get assistanceWhat you can expect

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

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

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”

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

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

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

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/

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

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

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

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

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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