Virginia Mason Insurance Grid ( )

Transcription

1 Aetna HMO Plans: Aetna Select Aexcel Plus Elect Choice EPO Open Access Managed Choice * *Insurance approved specialty care referral is not required if patient has PCP. POS Plans: QPOS Managed Choice POS Choice POS PPO Plans: Open Access Select, Elect and Managed Choice Open Choice USAccess NAP Aetna Medicare HMO Aetna Medicare Open Access HMO Aetna Medicare PPO * *Accepting for established primary care patients. If patient is non established in primary care accepting for specialty care referrals only. 1 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

2 Primary Care Amerigroup *Healthy Options (HMO) *Virginia Mason is not contracted. Unless emergency, specialty referrals and hospital admissions MUST be authorized by Amerigroup. If no authorization by Amerigroup, services will not be reimbursed. t accepting for psychiatry. Apple Health (formerly called Medicaid) Apple Health * *Accepting for established primary care patients. *t accepting for new patients into primary care. t accepting self-referrals for new specialty care patients. t accepting for psychiatry. Asuris rthwest Health PPO Network * *Contracted via Regence Medicare PPO * Blue Cross/Blue Shield out of Washington State PPO Network Medicare Advantage PPO BridgeSpan (Via Cambia, parent company of Regence) POS Exchange program Bronze Silver Gold Platinum * *t contracted, but members may use out-of-network benefits. Champus/ChampVA *Federal Program *Federal Program - ChampVA does not have a contracted provider network. However, Virginia Mason is not currently working with this program. 2 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

3 CIGNA PPO Network Managed Care (HMO) * *Insurance approved specialty care referral is not required if patient has a VM PCP. CIGNA Medicare Advantage PPO: Access Access Plus Access Plan One and Plan Three * Accepting for established primary care patients. If patient is non established in primary care accepting for specialty care referrals only. Community Health Plans of Washington (CHPW) *Healthy Options (HMO) *VM is not contracted. Unless emergency, specialty referrals and hospital admissions must be authorized by CHPW. If no authorization by CHPW, services will not be reimbursed. t accepting for psychiatry. HealthEssentials PPO (Exchange Program) Bronze Silver Gold * *HealthEssentials comes to VM via First Choice Health Network. Community HealthFirst Medicare Advantage HMO Confluence Health Confluence Health Health Alliance Medicare HMO * *Contracted through their partnership with Confluence Health. 3 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

4 Coordinated Care Corporation (Centene) Coventry (formerly called First Health) *Crime Victims Fund Edison Health First Choice Health Network *Healthy Options (HMO) *VM is not contracted. Unless emergency, specialty referrals and hospital admissions must be authorized by Coordinated Care. If no authorization by Coordinated Care, services will not be reimbursed. t accepting for psychiatry. *Ambetter (HMO Exchange Program) *VM is not contracted. Bronze Silver Gold Unless emergency, specialty referrals and hospital admissions MUST be authorized by Ambetter. If no authorization by Ambetter, services will not be reimbursed. PPO Network *Advantra Freedom Medicare Advantage PPO *t sold in Washington State Crime Victims Compensation Program * May apply if Patient sustained bodily injury or severe benefits. emotional stress resulting from a crime. * *Spinal and Heart services - a determination made by the Spinal Services Heart Services Program Administrator that all benefit program conditions have been met for each Participant, procedure, and other care delivered prior or after the admission for a procedure. PPO Network Includes Beech Street who now owns PPONext. VM Employee Plan GreatWest Healthcare PPO Network Owned by CIGNA, but continues to operate separately. Group Health Cooperative Alliant Plus/Connect (POS) 4 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

5 Health Design Plus (HDP) Alliant Select/Alliance (HMO) * *Insurance approved specialty care referral is not required if patient has PCP. Options POS * *Patient may incur higher out-of-pocket expenses as they would be out-of-network when choosing PCP Options Select (HMO) Options PPO Group Health Access PPO Group Health Core GHC Healthpays HSA Bronze *Kaiser Permanente *Kaiser is via their reciprocity agreement with GH PEBB Classic and Value Plan PEBB HSA Clear Care Medicare HMO Clear Care Medicare PPO Spinal Services Heart Services Hip/Knee Services * *Spinal and Heart services - a determination made by the Program Administrator that all benefit program conditions have been met for each Participant, procedure, and other care delivered prior or after the admission for a procedure. Humana PPO Network HumanaChoice Medicare PPO Humana Gold Plus Medicare HMO 5 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

6 Humana Community Medicare HMO Indian Health Services HMO program listed by tribe Interplan Health Group PPO Network Labor and Industry (L&I) Federal and State funded work Injury * *Patient would need to apply for L&I via their employer. If L&I approves as work injury they will pay. If they do not, bills will go to patient s health insurance. LifeWise (Contracted via Premera) LifeWise PPO LifeWise Essential (Exchange Program) ID card indicates LifeWise Connect. Bronze Silver Gold *Medicaid Out-of-State Other Out-of-State *Unless emergency, ALL out-of-state Medicaid (Alaska, Oregon, Montana, Colorado, Florida, Idaho, etc.) requires approved prior authorization via the respective out-of-state Medicaid program). If not prior approved, services will be denied. Medicare Part A and B Part A only Part B only Railroad 6 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

7 *Medicare Advantage (in addition to those mentioned throughout this document) (Medicare Advantage programs can be HMO, POS or PPO) PPO Columbia Community Care Desert Medicare Advantage First Seniority Freedom Plan HealthMarkets Care Assured Plans Health Net Pearl Plan Mennonite Mutual Aid Association (Team Care Advantage) Moda Health (formerly ODS) MVP Care New West Medicare Preferred Care Partners SecurityChoice Plus and Classic Sierra Health and Life Insurance Company (Sierra Optima Choice) Today s Options, Value and Premier by CCRx Today s Option PPO and PFFS (by Pyramid) True Value Medicare UniCare SecturityChoice Classic and Plus USA Care by Preferred Care WellCare (Concert, Serenade, * *Accepting for established primary care patients. *If patient is non established in primary care accepting for specialty care referrals only. 7 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

8 HMO Sonata, Melody) WindsorSterling Gold Plus Highline Medical Services Organization (HMSO) Molina Medicare Options Windsor Medicare Extra, Extra Comp Plus, Emerald, gold WindsorSterling Basic and Basic Plus Medicare Select *Medicare Select Networks *t accepted (unless emergency). Persons under the select programs are required to use contracted hospitals. Virginia Mason is not a contracted hospital and as such cannot admit patient. As this is the case, Virginia Mason is also not scheduling services se Medigap Medicare *Plans identified as Medicare Supplement programs. *Always secondary to Medicare. Supplement Plans Programs. Molina Healthcare Healthy Options (HMO) * *Virginia Mason is not contracted. Molina Gold and Silver (HMO Exchange Unless emergency, specialty referrals and hospital admissions MUST be authorized by Molina. Programs). If no authorization by Molina, services will not be reimbursed. t accepting for psychiatry. 8 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

9 Multiplan PPO Program Premera Blue Cross *Blue Cross/Blue Shield (BC/BS) Out-of-State Prudent Buyer PPO Traditional Indemnity *Premera Preferred (Exchange program) ID card indicates Heritage Signature. *Heritage Premier will be on the ID card. Bronze Silver Gold *Premera Medicare Supplement *This is a Medigap plan, not the BC/BS Medicare Advantage program. Always secondary to Medicare. All Dimensions Plans (including Heritage Networks) *Premera Medicare HMO *Virginia Mason is not currently contracted, but contract are discussions occurring. Premera Medicare Advantage HMO/POS * *Accepting for established primary care patients only. If patient is non established in primary care accepting for specialty care referrals only. Patient may incur higher out-of-pocket expenses as they would be out-of-network when choosing a Virginia Mason PCP Premera Medicare Advantage PPO * *Accepting for established primary care patients only. If patient is non established in primary care accepting for specialty care referrals only. 9 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

10 *Private Healthcare Systems (PHCS) Regence Blue Shield (Under the ownership of Cambia Health Solutions) SoundPath Health (formerly Puget Sound Health Partners) *TRICARE (UnitedHealthcare Military PPO Network *Owned by Multiplan, but operating as a separate organization at this time. *Boeing PPO *Administered by Blue Cross/Blue Shield (BC/BS) of Illinois. *Boeing Selections *Administered by Blue Cross/Blue Shield (BC/BS) of Illinois. Healthcare Management Administrators King Care (KRC) PPO (non-boeing) Regence Select Network (EPO) Selections POS (non-boeing) Classic (PPP) Medicare Supplement *This is a Medigap plan, not the Regence Medicare Advantage program. Always secondary to Medicare. Innova and Engage Federal Employee Plan (FEP) Individual Basic Blue Cross/Blue Shield (BC/BS) Out-of-State Regence BlueAdvantage Medicare HMO Regence Medicare Advantage PPO HMO * *Virginia Mason is not currently contracted, but contract Alpine Charter+ Pinnacle+ are discussions occurring. Apex+ Sound + TRICARE PRIME (HMO) * TRICARE Extra (POS) 10 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r

11 & Veterans) TRICARE Standard (POS) UnitedHealthcare (UHC) Community Plan Healthy Options (HMO) * *Established primary care patients only. Unitedhealthcare Options (PPO) Choice and Choice Plus (PPO) Signature Value West (HMO) Navigate AARP Medicare Complete Plus (HMO/POS) AARP Medicare Complete West - HMO */ *HMO - Referral for specialty care is required when one of the below primary care practices have been selected: Medicare Advantage PPO Highline Medical Services Organization, *Community Plan Dual Complete also Physicians Care Network, or called Evercare (HMO) Everett Clinic Primary Care Provider. *Virginia Mason is not contracted with Community Plan Dual (Evercare). Complete Uniform Medical Plan *PPO Network *Administered by Regence. Uniformed Services Family USFHP (HMO) USFHP is a TRICARE HMO program administered by Pacific Health Plan (USFHP) Medical Centers. Veterans Administration (VA) *Federal Program *The VA typically requires all services to be provided within VA medical centers. However, at times they will refer to non-va specialists. This most often occurs when they do not have the needed specialty, or, they have overflow issues. VA personnel MUST have VA authorization for all services within Virginia Mason. *te: If you have the VA and Medicare, you may choose to use either your VA benefits or your Medicare benefits. 11 P a g e V i r g i n i a M a s o n I n s u r a n c e G r i d, N o v e m b e r