 |
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
BlueCare Options BlueCare Options is a point-of-service plan. A point-of-service has two levels of benefits for most services--Preferred and Standard. You get Preferred benefits when you get referrals from your primary care physician and follow other managed care guidelines. When you receive Standard benefits, you share in the higher cost of your care through higher out-of-pocket costs (deductibles, coinsurance, etc.). For some services, BlueCare Options does not offer Standard benefits at all. You must follow managed care guidelines or you receive no benefits. More information about BlueCare Options appears below: Referrals with the BlueCare Options To get the best out of your benefits from BlueCare Options, 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. Generally, your primary care physician will refer you to specialists and other providers that belong to 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. When you have a referral, you receive Preferred benefits for the care you get from a provider other than your primary care physician. This means you pay lower out-of-pocket payments for your care. (For some services, BlueCare Options pays Standard benefits when you don’t meet managed care guidelines.) You don’t need a referral from your primary care physician for these services if you use a network provider:
Our Precertification Program We require a Preadmission or Admission Review for all hospital admissions. Calling us protects you from having to pay for unnecessary and noncovered hospital stays. Urgent and Emergency Care with BlueCare Options BlueCare Options 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 Preferred 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 Options Your plan covers preventive care, such as your annual physical, in full, with no-copayment. 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 Preferred benefits under your program. You will only pay a modest co-payment 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:
For many office-based services, you may choose not to follow referral guidelines, but you will only receive Standard benefits. These benefits require that you pay higher out-of-pocket payment to share in the higher cost of your care. For other services--mental health services, for example--you must follow managed care guidelines or you get no benefits at all. Check your Certificate of Coverage and Outline of Coverage to see which services are covered under Standard benefits. Hospital Admission with BlueCare Options When you need to go into the hospital for a scheduled stay, make sure to get the following authorizations:
If you don't get a referral from your primary care physician, you will receive only Standard Benefits for services. Higher out-of-pocket costs will apply. If you choose not to get a referral and get Standard Benefits, you will also need a preadmission review from TVHP (call 888-882-3600) to make sure we consider your admission medically necessary. If you don't get preadmission review from TVHP, you may have to pay a penalty of up to $1,000 in benefits when we cover your admission. If you don't get prior approvals for procedures, you may have to pay for the procedure yourself. Please check your contract materials carefully before a scheduled inpatient stay. 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. Mental Health and Substance Abuse Treatment with BlueCare Options 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 connect you with your care manager. You must use a regional 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 regional network approves your care. Check your Contract for details. To look for a mental health provider in your regional 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 a starter kit to the member. |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|