 |
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
 |
|
|
 |
|
|
 |
 |
|
|
|
 |
Frequently Asked Questions (FAQs)
Three Medical PlansWhat are the advantages of an HMO?Under an HMO, can I select my own doctor? Can I change my choice of doctors with the HMO? What if I go to a doctor outside of my HMO? What are the advantages of HMOs for families? Can I convert to an individual HMO policy if I lose eligibility under this Plan? Are services for medical emergencies a covered benefit under an HMO? What are the advantages of the Self-Funded Indemnity Plan? Can I convert to an individual Anthem Blue Cross policy if I lose eligibility under this self-funded Indemnity Plan? Can I receive medical care at any hospital under the Indemnity Plan? Under the Indemnity Plan, do I need to receive advance approval for non-emergency hospitalizations? If I am enrolled in the Indemnity Plan, and my doctor recommends surgery, will charges for a second opinion be a covered Plan benefit? Do I have any control over my out-of-pocket expenses under the Indemnity Plan? Are experimental or investigational procedures covered under any of the Plans? QUESTION: What are the advantages of an HMO? ANSWER: Under an HMO Plan, covered benefits are provided for no charge or for a fixed copayment. Your
out-of-pocket costs will generally be much lower under an HMO Plan than under the Self-Funded
Indemnity Plan. There are no claim forms to complete.
QUESTION: Under an HMO, can I select my own doctor? ANSWER: Yes provided the doctor is an HMO doctor under the Plan you selected. Each family member is
encouraged to select a personal physician.
QUESTION: Can I change my choice of doctors with the HMO? ANSWER: Yes, under both of the HMO Plans you are allowed to change to another doctor at any time subject
to the rules of the HMO selected.
QUESTION: What if I go to a doctor outside of my HMO? ANSWER: Unless the HMO you selected referred you to a specialist, there are no benefits available if you use
doctors outside of the HMO.
QUESTION: What are the advantages of HMOs for families? ANSWER: In view of the "affordability factor," parents can seek medical attention for their children as
concerns arise. Each HMO has established a limit on the total amount of copayments that you
would have to pay in any one year. The exact amount of this maximum copayment liability is
shown in the HMO's "Evidence of Coverage" brochure.
QUESTION: Can I convert to an individual HMO policy if I lose eligibility under this Plan? ANSWER: Yes provided you make written application to the HMO within the prescribed time period.
QUESTION: Are services for medical emergencies a covered benefit under an HMO? ANSWER: Generally yes, subject to the established rules of the HMO. Each HMO has specific benefits for
emergency services, within or outside the HMO enrollment/service area. Refer to the "Evidence of
Coverage" brochure from your HMO for specific details.
QUESTION: What are the advantages of the Self-Funded Indemnity Plan? ANSWER: You can go to any licensed doctor of your choice and be eligible for Plan benefits, and you are not
restricted to a specific service area. That is why the Indemnity Plan is also referred to as the
"freedom of choice plan." You will have less out-of-pocket costs when using the Anthem Blue Cross
Prudent Buyer PPO. The Administrative Office can furnish you with a Prudent Buyer directory for
an area where you live or work. Also refer to the section titled, "Self-Funded Indemnity Plan with
Anthem Blue Cross Prudent Buyer Plan (PPO)" subsection "Online Internet Website" where you can find
a Prudent Buyer provider online.
QUESTION: Can I convert to an individual Anthem Blue Cross policy if I lose eligibility under this self-funded Indemnity Plan? ANSWER: Yes provided you make written application to Anthem Blue Cross within the prescribed time period and
meet other requirements. Refer to the section entitled "Converting to Individual Policy" under the
Self-Funded Indemnity Plan section.
QUESTION: Can I receive medical care at any hospital under the Indemnity Plan? ANSWER: Yes, provided the following two conditions are met:
- 35 -
1. You are admitted to the hospital, by a licensed doctor of medicine, and
2. The hospital meets the Plan's definition of a hospital.
QUESTION: Under the Indemnity Plan, do I need to receive advance approval for non-emergency hospitalizations? ANSWER: Yes. The Plan requires that all non-emergency hospital stays be approved in advance. Refer to
section titled "Self Funded Indemnity Plan with Anthem Blue Cross Buyer Plan (PPO)" subtitled
"Summary of Hospital & Medical Benefits" for more details. When you use Participating Prudent
Buyer Providers, this will be accomplished with no action required on your part.
QUESTION: If I am enrolled in the Indemnity Plan, and my doctor recommends surgery, will charges for a second opinion be a covered Plan benefit? ANSWER: Yes. In fact, for all non-emergency surgeries, the Plan encourages you to obtain a second opinion.
QUESTION: Do I have any control over my out-of-pocket expenses under the Indemnity Plan? ANSWER: Yes. The Anthem Blue Cross Plan has contracted with select doctors and hospitals, who have agreed to
provide medical care at reduced rates. These doctors and hospitals are referred to as a Preferred
Provider Organization (PPO) under the Anthem Blue Cross Prudent Buyer Plan. For a complete
explanation, refer to table of contents titled "Self Funded Indemnity Plan with Anthem Blue Cross Prudent
Buyer Plan (PPO)".
QUESTION: Are experimental or investigational procedures covered under any of the Plans? ANSWER: All Plans, both HMO and the Indemnity Plan, have specific exclusions concerning experimental
and investigational procedures. Contact your benefit provider directly (Kaiser, PacifiCare or Anthem Blue
Cross) or the Administrative Office if you have any questions about a specific procedure.
|