|
Learn answers to your questions
Hometown Health Providers (PPO)
Hometown Health Providers (PPO) Answers to Your Questions
Q. What is a PPO?
A. PPO stands for Preferred Provider Organization. Hometown Health Providers gives members the option of receiving medical care from participating providers (those listed in our Hometown Health Provider Directory) or nonparticipating providers (those not listed in our Hometown Health Provider Directory) or a combination of both. When receiving care from a participating provider, there is generally a copayment for an office visit. You must identify yourself to a participating provider by presenting your Hometown Health membership card. For services other than nonprocedural office visits, you could pay a deductible or coinsurance or both, depending on the type of facility and the treatment or test. When receiving care from a nonparticipating provider, the appropriate coinsurance and deductible amount will apply for office visits.
Back to top
Q. Who is eligible for coverage?
A. Employees and dependents who meet their employer's eligibility guidelines and the guidelines defined in the Hometown Health Providers Evidence of Coverage booklet are eligible for health care coverage.
Back to top
Q. How do I apply for coverage?
A. Fill out all sections, sign, and date your "Hometown Health Enrollment Application/Membership Change Form" and return it to your employer. If you or your dependents do not apply when first eligible, you or your dependents or both may enroll at your group's next open enrollment or, if applicable, during the plan year if a change in life status occurs. See your employer for details.
Back to top
Q. What is the advantage of using a preferred versus a non-preferred provider?
A. With a participating provider, you enjoy:
- substantial reductions in your out-of-pocket expenses
- no claim forms
- no bills for services that are above and beyond usual and customary charges (balance billing by providers)
- a copayment for many services
In addition, you can be assured that all of our participating providers are thoroughly reviewed for consistent delivery of quality care before and during their contract with Hometown Health Providers.
Back to top
Q. What is my deductible?
A. Your deductible is a set amount of charges that must be paid by you before Hometown Health Providers covers the remainder. Please refer to your Schedule of Major Medical Benefits (Attachment A) for specific participating and nonparticipating deductibles.
Back to top
Q. What is my co-insurance amount?
A. Your coinsurance is a set percentage of certain covered charges you must pay. Please refer to your Schedule of Major Medical Benefits (Attachment A) for specific participating and nonparticipating coinsurance percentages and your maximum out-of-pocket expense for participating and nonparticipating coinsurance. When receiving care from a nonparticipating provider you will also be responsible for charges that are over usual and customary.
Back to top
Q. Do my co-payments apply toward my deductible or co-insurance?
A. No. You are always responsible for your copayments.
Back to top
Q. What is my lifetime maximum?
A. Your lifetime maximum benefit is $2,000,000 of covered benefits payable by Hometown Health Providers while you are under this policy. Refer to your Summary of Benefits, Attachment A, and Evidence of Coverage for limitations and lifetime maximums.
Back to top
Q. What should I do if I receive a bill?
A. You need to check with the provider to ensure that they have sent their billing to Hometown Health Providers for processing. If the provider is not a participating provider, they may be willing to bill on your behalf. If so, you will need to have the provider complete a medical claim form with all the pertinent information. These forms are provided in your enrollment packet. If you need additional forms, please contact our Customer Services Department to send you additional forms. If the provider is unwilling to bill Hometown Health for you, then you must submit your record of payment along with the claim form indicating whether you or the provider should be reimbursed.
Back to top
Q. What if the charges billed by a Provider are higher than "usual and customary"?
A. If you are using a participating provider, you do not have to be concerned about usual and customary charges. Hometown Health Providers has contracted fees with participating providers. If you are using a nonparticipating provider, you may be responsible for all excess charges (charges over and above usual and customary) and be billed by the nonparticipating provider for the balance of the bill.
Back to top
Q. Do I need referrals or authorizations?
A. Yes, for certain tests, procedures, and hospitalization, as indicated in your Schedule of Major Medical Benefits (Attachment A) or your Evidence of Coverage booklet. This will indicate when precertification is necessary. It is your responsibility to request precertification for certain procedures and tests. If preauthorization is not obtained your benefits will be reduced.
Back to top
Q. I'm pregnant. How can I receive obstetrical care through Hometown Health Providers?
A. You may select any participating OB/GYN for your care. You must obtain an authorization, however, for your hospitalization prior to delivery or within 48 hours of hospitalization in an emergency.
Back to top
Q. I don't know any of the doctors on your provider list. What should I do?
A. Our Customer Services Representatives will verify which providers are currently accepting new patients and provide you some basic information such as the type of practice, location, office setting (clinic vs. private practice) and appointment procedures. You can also call our Health Hotline at 775-982-5757 or 888-324-3243. By gathering as much information as possible, you can make a well-informed decision.
Back to top
Q. If Hometown Health Providers is my contracted pharmacy carrier, how are prescriptions covered?
A. If you go to a participating pharmacy (contracted with Hometown Health Providers): Your prescriptions will be filled up to a 30-day supply. Hometown Health Providers covers all A/B approved generic drugs for a low copayment. If your prescription is for a brand-name drug that is on the Hometown Health Formulary (the list of approved medications) and has no generic equivalent, you will pay a slightly higher copayment. Should your physician prescribe a brand-name drug that has a generic equivalent or is not on the formulary, you will be responsible for a higher copayment or a deductible and coinsurance, depending on your coverage.
If you go to a nonparticipating pharmacy (a pharmacy not contracted with Hometown Health Ins. Co.): Your prescriptions for FDA-approved drugs will be covered as a nonparticipating benefit as shown on your prescription drug rider. You will first have to pay your nonparticipating prescription drug deductible of $100, and then you will be responsible for 30 percent of the billed charges.
If you are eligible for Hometown Health Providers' Mail Order Prescription Drug Program: Hometown Health Providers has this additional resource for obtaining prescription drugs through a mail/phone order program. You can receive up to a 90-day supply after your first fill of that prescription - if allowed under FDA guidelines – and our mail order service will deliver it right to your home. If you have the 90-day prescription filled at a local retail pharmacy, you will be responsible for paying three times the copayment amount.
Back to top
| Q. How can I replace my lost Hometown Health ID card? |
| A. You can request a new membership card by calling our Customer Services Department at 775-982-3232, or 800-336-0123. Hometown Health will send a replacement card to your home address within five working days of your request. |
Back to top
Q. I will be moving soon. How do I notify Hometown Health Providers of my new address?
A. Hometown Health Providers must have your correct address and telephone number. We notify members about any precertifications, program or physician changes, and claims status by mail. Also, we want to make sure you receive each issue of our newsletter, Hometown Healthy Connection. Please fill out an "Hometown Health Enrollment Application / Membership Change Form" at your human resources department, call our Customer Services Department before you move, or mail us a change of address card (available at your local post office).
Back to top
Please see your Evidence of Coverage for a detailed description of benefits
|
|
