Health Net Blue & Gold HMO

Transcription

1 University of California Health Net Blue & Gold HMO We ve got you covered! Created for UC employees and non-medicare retirees October 2016

2 Health Net Blue & Gold HMO Smart. Affordable. Health care made easy! 2016 is the year to get covered with a health plan that s comprehensive, affordable and easy to use. Get covered with Health Net Blue & Gold from Health Net of California, Inc. (Health Net). You ll be in good company over 43,000 UC employees and retirees are already Blue & Gold! We re here for you! Call Health Net s UC dedicated Customer Contact Center at if you have questions or want help evaluating your health coverage choices for We re open Monday through Friday, 8:00 a.m. to 6:00 p.m., Pacific time. After hours, Health Net has an Interactive Voice Response (IVR) system available at the same number. Or us at ucwell@healthnet.com. About Health Net Blue & Gold HMO 1. What is Health Net Blue & Gold HMO? Health Net Blue & Gold HMO is a health plan created five years ago exclusively for University of California employees and non-medicare retirees and their families. If you want simplicity, value and affordability, Health Net is a great choice. 2. Why was Health Net Blue & Gold HMO created? The continually rising costs of health care and the university budgetary challenges have created a vital need to explore different health benefit strategies. Since 2011, the university has partnered with Health Net to offer a health plan option that makes coverage more affordable for employees and non-medicare retirees, while ensuring access to quality care. 3. Why should I consider joining Health Net Blue & Gold HMO? When you re Blue & Gold, you re really covered. Health Net Blue & Gold gives you: 1. A flexible, easy-to-use HMO plan. No claims to file and no deductibles to track. 2. Predictable costs with fixed copayments for services a great value. 3. A choice of providers you know. All of the UC medical centers and physicians groups are part of the Blue & Gold Network. There s a good chance that your doctor is, too. If not, there are many quality physicians to choose from. 4. Coverage you can count on with a primary care physician (PCP) to coordinate your care, after hours care, plus urgent care centers for more convenience and lower copayments than emergency rooms. 5. Access to award-winning health education programs that support you in improving and maintaining your health and well-being. Health Net for UC 2016: FAQ Page 2

3 When it comes to your health, experience matters. We ve been serving Californians for over 35 years and a UC-sponsored health plan for nearly as long. Health Net is health coverage you can trust. About Our Network 4. How was the Blue & Gold HMO network developed? The university worked closely with Health Net to establish criteria for the Blue & Gold HMO network. Affordability was a key factor, but other factors included: Offering access in all 30 California counties. Incorporating the largest possible number of doctors currently caring for UC employees, non-medicare retirees, and their families into the network. Having all the University of California medical groups and centers participate. 5. Does Health Net make changes to the network every year? Health Net continues to monitor our Blue & Gold HMO network for affordability and accessibility. Providers may be added or removed based on whether they meet the participation criteria for the Health Net Blue & Gold HMO network stated above. We work closely with the provider community to minimize Blue & Gold HMO network changes each year. 6. Are there changes to the Blue & Gold HMO network? There are no changes to the Health Net Blue & Gold HMO network, effective January 1, Where can I find a full list of available Blue & Gold HMO doctors, medical groups and hospitals? The complete Blue & Gold HMO network list is online at Click ProviderSearch to begin your search. The online information is always the most current; however, you can also call the dedicated Customer Contact Center for UC at to get help with choosing doctors or medical groups. 8. Are the UC medical groups and medical centers included in the Blue & Gold HMO? Yes, all UC medical groups and medical centers are included in the Health Net Blue & Gold HMO network. Plus, all UC medical groups now have accountable care organization (ACO) arrangements. An ACO is a health care arrangement between doctors, hospitals and insurers to improve the coordination, quality and cost of health care. What it means to you: You get a focused team of health care experts working together for you. Health Net for UC 2016: FAQ Page 3

4 For 2016, Blue & Gold HMO members who choose any of the following medical groups/centers will automatically get the ACO team approach: UC Davis Medical Group UCLA Medical Group UCI University Physicians and Surgeons UCSD Healthcare Network UCSF, including Hill Physicians, UCSF Medical Center, Dignity Health (St. Mary s Medical Center and Saint Francis Memorial Hospital) John Muir Physicians Network Choosing a medical group that includes an ACO is something to consider if you live or work near one or if your doctor (or the doctor you want) is part of the group. Of course, all medical groups in the Blue & Gold HMO network are known for their quality care and commitment to your health. You can t go wrong no matter which medical group you choose when you have Blue & Gold! 9. Why isn t my medical group included in the Blue & Gold HMO? If your medical group isn t in the network, it means that they did not meet the criteria for affordability and access required to participate. 10. There has to be a catch. Is the quality of Health Net Blue & Gold doctors lower? No. The Blue & Gold HMO network may be a little smaller, but that doesn t mean it isn t big on quality. If your doctor isn t already a part of the network, you can be assured that no matter whom you choose the choice will be a good one. All of our providers are required to maintain credentialed status and adhere to industry-approved clinical practice guidelines. About Our Benefits 11. Are there any benefit changes for this year? Yes, we have an enhancement for you! Effective January 1, 2016: Travel and preventive immunizations are now covered at 100%. 12. How does the chiropractic/acupuncture benefit work? Health Net has teamed up with American Specialty Health Plans of California, Inc. (ASH Plans) to offer Blue & Gold HMO members affordable chiropractic and acupuncture coverage. You re free to obtain care by selfreferring to a participating chiropractor/acupuncturist. The provider s treatment plan will be reviewed and must be approved by ASH. Visits will require a $20 copayment. Up to 24 visits are covered per year, combined for both chiropractic and acupuncture services. Health Net for UC 2016: FAQ Page 4

5 To find participating chiropractors/acupuncturists, go to and click ProviderSearch. 13. Are there other services available to members beyond doctor visits and medications? Yes. Health Net Blue & Gold HMO has added benefits that bring you the latest and best health care available at no extra cost, including: Telehealth with MDLIVE (via phone or Internet with secure video) Is it after hours and your PCP isn t available? Are you in need of care while traveling? Health Net has partnered with MDLIVE to bring you access to medical help, 24 hours a day/seven days a week! MDLIVE has a national network of board-certified physicians who provide quality care through the convenience of phone, online video or secure consultations. Telehealth does not replace your primary care physician, but if you are considering the use of an urgent care center or emergency room for treatment of a non-emergency illness or injury, you should consider the MDLIVE program. These providers can diagnose, treat and write prescriptions for routine medical conditions, making health care more accessible, affordable and convenient for you. Surgery decision-support Health Net is happy to offer access to Welvie SM an online program that helps you decide on, prepare for, and recover from surgery. If you re undecided about surgery, the program guides you through the entire decision-making process. Or, if surgery isn t in your immediate future, the program can help you so that you ll be prepared when it is. There is no cost to use Welvie, and Health Net offers a $25 Amazon gift card for participation. Medicare members are not eligible for this incentive. Proactive diabetes and heart disease prevention It s easy for members to enroll in the Prevent Program, our partnership with Omada Health. This groundbreaking 16-week online weight loss and management program is designed to help you improve your health and avoid preventable diseases like diabetes and heart disease. Quit For Life Coaches are available with one-on-one telephonic support to help you quit smoking or using tobacco. 14. Telehealth? Telemedicine? Is this a safe way to receive health care services? Yes. The MDLIVE physicians are fully credentialed on an annual basis using NCQA and URAC guidelines and have passed background checks with primary verification using the National Practitioner Databank and the American Medical Association. MDLIVE physicians follow national standards of medical practice. If unable to treat a patient using the appropriate standards of care for telemedicine, the MDLIVE physician directs the patient to seek care from an alternative medical provider. A consultation with an MDLIVE physician is similar to the care received from physicians when you call them after hours for medical assistance. Health Net for UC 2016: FAQ Page 5

6 15. Will the MDLIVE physician send a treatment report to my primary care physician? Yes. This can be done with your permission. The MDLIVE online individual member portal has a primary care physician tab where you can enter your PCP information and grant permission for records of the telemedicine visits you have with MDLIVE to be shared with your PCP. About the Out-of-Pocket Maximum 16. What is an out-of-pocket maximum (OOPM)? Once the total amount of all copayments you pay for covered services in one calendar year equals the out-of-pocket maximum (OOPM) amount, no payment for covered services and benefits may be imposed on you. The Health Net Blue & Gold OOPM amounts for the 2015 plan year are: One member $1,000 Two members $2,000 Family (three or more members) $3, What services are excluded from the out-of-pocket maximum? While both medical and prescription drug copayments will apply to the OOPM for the 2015 plan year, there are some exclusions: Covered services from a nonparticipating provider will not apply toward the OOPM unless the prescription is for the first 30 days of coverage (new member) or in cases of an emergency or urgently needed care. Ancillary charges (the cost difference between the brand and the generic) when the member receives a brand-name drug when a generic is available will not apply toward the OOPM. About Pharmacy Benefits 18. How do I get my prescriptions if I join Health Net Blue & Gold HMO? A 30-day supply of a prescription drug is available from your retail pharmacy. You can get up to a 90-day supply of maintenance drugs through our mail-order program or at UC Walk-Up Services at UC Medical Centers or a CVS retail pharmacy location. 19. What is a maintenance drug? A maintenance drug is a prescription drug taken regularly to manage chronic or long-term conditions such as high blood pressure, asthma, diabetes, or high cholesterol. Health Net maintains a list of maintenance medications eligible for a 90-day supply. This list is posted at click Pharmacy. Health Net for UC 2016: FAQ Page 6

7 20. What are my options for getting maintenance drugs? Specific maintenance medications listed on the Health Net Maintenance Drug List are available for a 90-day supply a UC walk-up pharmacy, a CVS retail pharmacy or CVS/caremark Mail Service Pharmacy. You will pay two copayments for a 90-day supply of maintenance medications. Consider what choice works best for you: Advantages of CVS/caremark Mail Service Pharmacy: Enjoy convenient home delivery Receive drugs in confidential, tamperresistant and (when necessary) temperature-controlled packaging Talk to a pharmacist by phone Advantages of a CVS retail pharmacy or UC walk-up pharmacy: Pick-up your long-term drug directly from the pharmacy at a time that is convenient for you Enjoy same-day prescription availability Talk face-to-face with a pharmacist 21. What drugs are not considered maintenance drugs? Examples of drugs that are not considered maintenance drugs include antibiotics to treat infections, drugs used for pain and/or acute medical conditions, drugs that have a specified course of therapy, drugs where the physician is monitoring the dosage for a patient and may make additional changes, or drugs not taken on a daily basis. 22. Is there a Mail Order Pharmacy program? CVS/caremark is Health Net s Mail Service Pharmacy. Using mail order gives you the convenience of home delivery for maintenance drugs And it saves you money! Your copayment will be equal to a 60-day supply while you receive up to a 90-day supply of your maintenance drug. For example, if you pay $25 for a 30-day supply of a brand-name maintenance drug, you will pay $50 for a 90-day supply of the drug at the CVS/caremark Mail Service Pharmacy, at a local CVS retail pharmacy or a UC walk-up pharmacy. That s a 33% savings! 23. Can I fill any prescription for a 90-day supply? No. Non-maintenance drugs and drugs not on the Health Net Maintenance Drug List are not eligible to be filled for a 90-day supply through a CVS retail pharmacy, UC walk-up pharmacy or the mail order pharmacy. 24. What do I or a family member have to do if a maintenance drug is being filled as a 30- day supply at a UC or CVS pharmacy? UC and CVS pharmacies can only fill for the quantity written on the prescription. To obtain a new 90-day prescription, members can: call their physician and ask for a new prescription, or Health Net for UC 2016: FAQ Page 7

8 visit their local UC or CVS pharmacy where the staff can contact their physician, or call CVS/caremark at They will contact your doctor to get your prescription information. 25. What if my physician refuses to provide a 90-day supply of my drug? Your physician may not want you to have an extended supply of your maintenance drug. Your physician may want to change the dose, evaluate your response or may feel the extended supply may be a safety concern. Writing for an extended day supply is up to your physician. 26. Will the pharmacy ask me if I want a 90-day supply? The pharmacy will process your prescription the way your doctor has written it. If your physician has requested a 90-day supply, the pharmacist will process a 90-day supply. If your prescription is for a 30-day supply and you wish to obtain a 90-day supply, ask the pharmacist to contact your physician to request a new prescription for the 90-day supply of your maintenance medication. Only maintenance drugs on the Health Net Maintenance Drug List are eligible to be filled for a 90-day supply at your mail order copayment. 27. Do I have to use the CVS/caremark Mail Service Pharmacy, a CVS retail pharmacy or a UC walk-up pharmacy for my maintenance drugs? No. Maintenance drugs may be obtained at any retail pharmacy contracted with Health Net. However, to obtain a 90-day supply of your maintenance drug, you will have to use a UC walkup pharmacy, a CVS retail pharmacy or CVS/caremark Mail Service Pharmacy. About Enrollment in the Blue & Gold HMO 28. If I am a Health Net Blue & Gold member today, do I need to do anything during Open Enrollment? No. If you are a current member and would like to continue with Health Net Blue & Gold HMO, you do not need to make any health plan changes during Open Enrollment. 29. How do I join the Health Net Blue & Gold HMO? During Open Enrollment, go to and select Health Net Blue & Gold HMO. When making your plan change, select a PCP for yourself and each covered member in your family. This election must be made between October 29, 2015, at 8:00 a.m. and November 24, 2015, at 5:00 p.m., and will become effective January 1, Can I enroll in Health Net Blue & Gold HMO if I m in Medicare? No. Health Net Blue & Gold HMO is open only to employees and non-medicare retirees. You are qualified for Health Net Blue & Gold if you are a non-medicare retiree or the non-medicare dependent of a Medicare retiree. Health Net for UC 2016: FAQ Page 8

9 31. Can I enroll myself in Health Net Blue & Gold HMO and a family member in a different health plan offered by UC? No. All covered dependents must enroll in the same plan as the UC employee or non-medicare retiree. 32. I m currently not a Health Net member. Am I eligible to join? As long as you live in the Health Net HMO service area, you can join Health Net Blue & Gold HMO. The open enrollment materials you receive from the university will list all the medical plan choices available to you. About Continuity of Care 33. What happens if I m currently in treatment and my doctor is not available as part of the Blue & Gold HMO network? Health Net s Customer Contact Center can assist you if your doctor isn t part of the Blue & Gold HMO network. Depending on your specific situation, your options may include establishing care with a new provider or requesting continuity of care benefits. Health Net provides continuity of care benefits for members who are currently receiving care for any of the following conditions and will continue to be on January 1st: An acute condition. A serious chronic condition. A pregnancy, including the immediate postpartum period. A terminal illness. Care for a child between birth and age 36 months. A surgery or other procedure scheduled to occur within 180 days of January 1st. If any of these conditions apply to you, please call Health Net s Customer Contact Center at so we can tell you more about the continuity of care benefit and, if applicable, help you complete the Continuity of Care Request Form and connect you to a case manager. We will contact all members who submit a Continuity of Care Request Form to confirm receipt and obtain any additional details needed. We may need a copy of your medical records to further process your request. Health Net s medical management clinical staff reviews all requests. The review considers your clinical status and needs against the continuity of care criteria. Once we make a decision, we will contact you by telephone or mail. For situations that do not qualify for continuity of care benefits, a Health Net case manager can assist in establishing care with a new network provider(s) and in coordinating care. ### Health Net for UC 2016: FAQ Page 9