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BlueCare BlueCare is an HMO (Health Maintenance Organization) program. It covers your care only when you get referrals from your primary care physician and follow other managed care guidelines. More information about BlueCare appears below: Referrals with BlueCare To get benefits through BlueCare, you should get most of your care from your primary care physician. You pay only a small co-payment each time you see this doctor. Also, you have the security of knowing that one doctor is monitoring all of your care and looking after all of your health needs. Sometimes your primary care physician won’t be able to give you a particular type of care. For example, you may need surgery. Or you may have a condition that could better be treated by a specialist. In this case, your doctor will write you a referral. Your primary care physician will most often refer you to specialists and other providers that are in The Vermont Health Plan's (TVHP) network. If you selected a primary care physician in the Central Vermont Network, your primary care physician will direct your care to Central Vermont Network specialists. You don’t need a referral from your Primary Care Physician for these services if you use a network provider:
Urgent and Emergency Care with BlueCare BlueCare has guidelines for urgent care and emergency care. In both cases, you may need quick care. We consider your problem "urgent" if going without care for 24 hours might put your health in danger. We call your problem an "emergency" if going without care right away might put your health in danger. If you need urgent care, call your Primary Care Physician. We don't provide benefits for urgent care not managed by your Primary Care Physician. TVHP Primary Care Physicians are on call or have coverage 24 hours a day, seven days a week. After hours, you may have to leave a message with an answering service. Your doctor or a covering doctor will return your call. A provider will see you within 24 hours of when you ask for urgent care. For some urgent problems, your doctor can treat you in the office. Other times, you may have to go to the emergency room. Your doctor will tell you what to do. In emergencies, you need care right away. An emergency occurs when a person with average knowledge of health and medicine expects the condition or illness, if not treated immediately, to result in serious harm to your physical or mental health. Emergencies might include:
Office Visits with BlueCare Use your primary care physician for most care. Always call your primary care physician before seeking treatment. This physician will provide you with preventive care and most of the other care you need. When you need care from another provider, such as a specialist, your primary care physician will manage your care for you. He or she will write you a referral. If you follow these guidelines, you will receive benefits under your program. You will only pay a modest visit fee each time you go to the doctor. You don’t need a referral from your primary care physician for the following office-based services if you use a network provider:
Hospital Admission with BlueCare When you need to go into the hospital for a scheduled stay, make sure to get the following authorizations:
If you go into the hospital for an emergency or maternity condition, you may call us after admission for approvals--preferably within 48 hours after you enter the facility. For mental health and substance abuse admissions, we have different procedures. With BlueCare, you don’t need a referral from your primary care physician for mental health or substance abuse treatment. Instead, call your local mental health and substance abuse network. Care managers there must give you prior approval. You may reach a mental health and substance abuse care manager by dialing, toll-free, (888) 882-3600 and asking our customer service representative to transfer you to your mental health network. You must use a network provider for care. Your mental health and substance abuse care managers will help you find the right provider for your needs. Remember, we only provide mental health or substance abuse benefits when your network approves your care. Check your Contract for details. To look for a mental health provider in your Network, visit our Find a Doctor site. We have ensured that you can find care easily in the network. There should be an outpatient facility within a 30-minute drive from your home. There should be an inpatient facility within a 60-minute drive. Please see Mental Health Exclusions or check your certificate for details on what is not covered. Better Beginnings Program Better Beginnings helps babies get the best start in life by providing their parents with educational materials, such as popular books and CPR classes. We also cover skilled nursing and housekeeping visits to help parents after their babies leave the hospital. Throughout a pregnancy, our nurses keep in touch with a mom-to-be to ensure she's getting the best possible care and the benefits to cover it. To join the program, a member should call our customer service department during the first trimester of her pregnancy. Our Better Beginnings representative will then mail her a starter kit. |
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