Principal HMO Health Insurance Plan

The text presented in this web page is directly from the booklet provided by The Principal Life Insurance Company, which is the Member Handbook issued to American Bank. It has been edited only insofar as necessary for it to be viewed on this website.

Topic Guide

Service Area Telephone Numbers
Selecting Your Primary Care Physician
Changing Your Primary Care Physician
When Your Primary Care Physician is not Available
Scheduling and Cancelling Appointments
Referrals and Authorizations
Hospital Admissions
Emergency Care in and out of the Service Area
The "Five W's"
Membership Identification Card
Member Payments
Eligibility Guidelines
Member Services
Member Rights and Responsibilities

 

HMO MEMBERSHIP HANDBOOK

INTRODUCTION

Principal Health Care of Florida, Inc. is pleased you have chosen one of the most innovative and flexible health care plans available anywhere ­­ Principal Health Care HMO. Membership in our Health Plan assures you that you and your family members will receive better benefit coverage compared to traditional health insurance. When you and your family use our Participating Physicians and Participating Providers, you receive 100% payment for covered services, except for applicable Co-payments.

Principal Health Care of Florida is a Florida licensed health maintenance organization (HMO) dedicated to providing quality health care at an affordable price. The Health Plan offers prepaid health care benefits plans to employers for employees and their dependents. The Health Plan provides its members the security of knowing they are being offered a health care delivery system supported by a long tradition of quality and service.

As an Independent Practice Association (IPA) model HMO, the Health Plan is composed of a dedicated network of individual physicians in private practice who see Health Plan members in their offices. The Health Plan also has arrangements with hospitals and other health care providers to care for its members. This is one way to keep the cost of quality health care affordable. The Health Plan works with this network of providers in the areas of marketing and administration, while also assisting in managing your health care costs.

This HMO Membership Handbook (Handbook) will assist you in taking full advantage of your membership. It explains how to receive care, what to do in an emergency, and other important information about your rights and responsibilities as a member.

Our HMO Group Member Services Contract is part of the Handbook. Please read the HMO Group Member Services Contract and this Handbook carefully!

Make sure that your enrolled family members are familiar with the Health Plan and how to use it. If you have any questions, please call:

Jacksonville Service Areas

(904) 390­0935 or (800) 358­6205

or

All other Service Areas

(904) 484­4000 or (800) 426­8072

 

SELECTING YOUR PRIMARY CARE PHYSICIAN

At the time you complete your Group Enrollment Form, you must select a Primary Care Physician for yourself and each member of your family. A Primary Care Physician may be selected for the entire family or a different Primary Care Physician may be selected for individual family members. The only requirement which must be met is that a Primary Care Physician must be selected for each family member. New members will select their Primary Care Physician from a current list of Participating

You and your Primary Care Physician will work together to maintain your good health. Your Primary Care Physician will provide and coordinate the majority of your health care needs including routine health problems, consultation with specialists and other providers. Medical Emergency care and hospitalization. In the event you require specialized medical care or hospitalization, your Primary Care Physician will arrange for necessary referral, authorization and treatment.

CHANGING YOUR PRIMARY CARE PHYSICIAN

If you wish to change your Primary Care Physician, you must notify our Member Services Department and request reassignment. The change is immediate after Member Services receives an application or request by phone. You may change your Primary Care Physician no more than twice a year, unless extenuating circumstances exist.

WHEN YOUR PRIMARY CARE PHYSICIAN IS NOT AVAILABLE

Primary Care Physicians are responsible for providing 24­hour coverage for their patients, including after normal business hours as well as on weekends and holidays. Should you require medical attention, contact your Primary Care Physician's office and identify yourself as a Principal Health Care of Florida member.

If your Primary Care Physician is unavailable, the office staff may refer you to a physician on­call. The on­call physician will give you further instructions. Many physicians use an answering service after normal business hours. It is a good idea to check with your Primary Care Physician to find out the particular method of handling after­hours calls. After­hours recordings and answering services that refer Members to an emergency room do not constitute authorization of services.

SCHEDULING AND CANCELLING APPOINTMENTS

When you want to see your Primary Care Physician, call his or her office directly to schedule an appointment. Always identify yourself as a Principal Health Care of Florida member and state the reason for your call ­­ an emergency or a request for a routine office­visit. If you are unable to keep a scheduled appointment, call your Participating Provider as soon as possible to cancel the appointment.

REFERRALS AND AUTHORIZATIONS

Your Primary Care Physician will be responsible for your total health care management. He or she will refer you to a specialist when needed or obtain authorization for you to receive additional treatment and/or hospitalization. After you have obtained a referral and/or authorization from you Primary Care Physician, you may make an appointment directly with a specialist or obtain hospital services. You are responsible for knowing the number of approved visits and the time frame for those visits. All services must begin within the validity period of the referral. Referrals obtained from your Primary Care Physician, after you have already seen or been scheduled to see a Participating Provider, are not valid. Therefore, retroactive referrals are not covered.

Visits to specialists must be arranged and authorized by your Primary Care Physician. A specialist cannot refer you directly to another specialist. Non­emergency care received without your Primary Care Physician's approval is not covered by Principal Health Care.

Members are allowed one annual visit, without a referral, to their participating OB/GYN for gynecological services, to include an annual pap­smear test. Any additional visits or services will require a referral from the members Primary Care Physician. Members receiving obstetrical care, including pre­natal and post­natal care, will require one initial referral only.

HOSPITAL ADMISSIONS

If hospitalization is required, your Primary Care Physician will arrange admission to one of the Health Plan's participating hospitals. Either your Primary Care Physician will admit you or you will be referred to a Participating Provider who will manage your inpatient care in coordination with your Primary Care Physician. Your admitting physician will give you instructions about which hospital to go to, including the date and time you should arrive.

If you will be having a baby, or if you know several days ahead of time that you will be admitted to a hospital, it is probable that the hospital will have your complete pre­admission forms. Be sure to tell the hospital you are a Principal Health Care of Florida member and remember to present your identification card when you are admitted. These procedures will assure that the Health Plan is appropriately notified.

All non­emergency hospital admissions must be authorized by your Participating Physician and approved by the Health Plan prior to your admission.

The admitting physician is responsible for notifying the Health Plan of your admission. You may wish to verify with your physician that approval has been obtained prior to your planned admission.

Principal Health Care of Florida will review your hospital chart during your stay to verify that you are receiving the appropriate care for your condition. When your condition no longer requires care in a hospital setting, our staff will help you and your physician make arrangements to care for you at home or at another acceptable setting.

EMERGENCY CARE IN AND OUT OF THE SERVICE AREA

Services for Medical Emergencies, including Medical Emergency services in a hospital, a physician's office or other ambulatory setting, are covered when you have a true life threatening emergency or when there is a sudden and acute onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:

· Permanently placing the member's health in jeopardy.

· Serious impairment to bodily function.

· Serious and permanent dysfunction to a body organ or part.

· Other serious medical consequences.

If you have a Medical Emergency and you are in the Service Area, call your Primary Care Physician to seek medical attention or advice. Your Primary Care Physician has your records, knows your medical history, and is the physician best suited to help you to determine your need for emergency medical care. If delay would jeopardize a life or result in serious health impairment, go to the nearest emergency facility to seek medical care, and notify your Primary Care Physician and the Health Plan about your Medical Emergency within forty­eight (48) hours or within a reasonable time period as dictated by the circumstances. If admission to the hospital is recommended, ask the emergency room personnel to contact your Primary Care Physician immediately. Your Primary Care Physician knows you and will see that you receive the best possible care. Follow­up care must be provided by your Primary Care Physician.

If a Medical Emergency occurs while you are out of the Service Area, seek medical attention immediately, and notify your Primary Care Physician and the Health Plan about your Medical Emergency within forty­eight (48) hours or within a reasonable time period as dictated by the circumstances. If Medical Emergency services are provided by an out­of­area emergency room or physician, follow­up services will normally be performed by your Primary Care Physician. Ground ambulance transportation to return you to a Participating Provider is covered, when pre­authorized by the Health Plan. Refusal to be transferred may result in loss of benefits.

If you go to an emergency room, whether it is in or out of the Service Area, and the condition is not a Medical Emergency, you will be responsible for payment of the emergency room and any associated bills, even though you may have been referred there by your Primary Care Physician or other Participating Provider. The determination of coverage for services rendered in an emergency room is based on the Health Plan's review of your medical records, along with those relevant symptoms and circumstances which preceded the provision of care. The Health Plan will pay, less required co-payments, any covered benefits for hospital and professional services if your Primary Care Physician and the Health Plan is notified of your Medical Emergency within forty­eight (48) hours or within a reasonable time period as dictated by the circumstances.

It is important that you know how to recognize a Medical Emergency, because there may be situations where services rendered in an emergency room do not meet the definition of a Medical Emergency and are not covered benefits. Please see the Appendix in the HMO Group Member Services Contract for a definition of a Medical Emergency. Use of an emergency room for a non­Medical Emergency is a costly way to obtain medical care and is not covered.

THE FIVE Ws

For easy use of the Health Maintenance Network option, remember the five Ws.

Who: Always carry your Principal Health Care of Florida identification card and identify yourself as a Principal Health Care of Florida member whenever you receive health services.

When: When you need medical care, contact your Primary Care Physician first. If delay

would jeopardize a life or result in a serious health impairment, you may go to the nearest emergency facility to seek medical care. In any case, your Primary Care Physician and the Health Plan must be notified of a Medical Emergency within forty eight (48) hours of its onset, or within a reasonable time period as dictated by the circumstances.

Where: Familiarize yourself and your family with the location of participating hospitals, pharmacies, laboratories and related health care organizations within the Health Plan. It is the member's responsibility to use only Participating Physicians, laboratories, X­ray facilities, pharmacies, and other Participating Providers.

Whatever: Never hesitate to call us. No problem, question or concern is too small or unimportant for us to know about. Our job is to serve you. Call before you seek services if you are not sure how to proceed. This will minimize problems.

Why: If you follow these guidelines, you will receive the most value from your benefits for the least cost to you.

MEMBERSHIP IDENTIFICATION CARD

Every Health Plan member receives a membership identification card. Carry your identification card with you at all times, and present it whenever you receive care from a physician, hospital, or other provider.

MEMBER PAYMENTS

Any required co-payments are to be paid by you directly to your Primary Care Physician or Participating Provider as indicated on your Schedule of Benefits in the HMO Group Member Services Contract. Only your co-payments payments apply to your out­of­pocket maximum. You should maintain accurate records of the co-payments you make, as it is your responsibility to determine when the out­of­pocket maximum is reached.

It is also your responsibility to inform the Health Plan on a Group Enrollment Form of any additional health insurance your family may have so that payments can be properly coordinated between the Health Plan and the other insurer.

Your Primary Care Physician and Participating Provider will bill us directly. Frequently, you will receive for your records a cony of the bill which has already been sent to Principal Health Care of Florida. However, in the event you receive an original bill, send the bill to us with a brief note of explanation, and the Health Plan will pay the Participating Provider for all covered services, less co-payments.

ELIGIBILITY GUIDELINES

To ensure that you and your family have uninterrupted coverage, we must receive a Group Enrollment Form, approved by your employer, within thirty­one (31 ) days of any changes in your family coverage. Group Enrollment Forms are available from your employer. Please refer to Article 6 in your HMO Group Member Services Contract to determine which of your family dependents are eligible for coverage.

MEMBER SERVICES

Principal Health Care of Florida values your questions and comments about the Health Plan or your health care to improve our services. Our Member Services staff will work with you to resolve any problems which you may experience during your membership. Please refer to Article 7 of your HMO Group Member Services Contract for specific details on our complaints and grievance procedure. It is our goal to resolve any concerns you have as quickly and satisfactorily as possible.

Our Member Services staff is available Monday through Friday during normal business hours to answer your questions, assist you with solving your problems, and to listen to your comments. Our telephone numbers are:

Jacksonville Service Areas Member Services

(904) 390­0935 or (800) 358­6205

All other Service Areas

(904) 484­4080 or (800) 426­8072

 

MEMBER RIGHTS AND RESPONSIBILITIES

As a member of Principal Health Care, you have the right to:

• Be treated in a manner reflecting respect for your privacy and dignity as a person.
• Not be discriminated against because of age, disability, race, color, religion, sex, or national origin.
• Be informed regarding diagnosis, treatment and prognosis in terms that you can be expected to understand.
  
• Receive sufficient information to enable you to give informed consent before the initiation of any procedure and/or treatment.
  
• Refuse treatment to the extent permitted by law, and to be made aware of the potential medical consequences of such action. Refusal of treatment may result in termination of membership if it precludes the establishment of a sound physician­patient relationship and/or jeopardizes the ability of the physician to care for you properly.
  
• Expect that all communications and records pertaining to your health care will be treated as confidential, and that no such records will be released without your authorization. Your signature on the enrollment form constitutes permission for release of medical records to PHC for you or your family dependents as listed on the enrollment form.
  
• Select your own personal physician from among Principal Health Care's participating primary care physicians and to expect that physician to provide quality care, and to arrange for and coordinate all care you receive.
  
• Reasonable access to necessary medical services.
• Express a complaint, as outlined in the Member Grievance Procedure, and to expect an answer within a reasonable period.
  
• Call us whenever you have a question about our HMO or your benefits. We are here to serve you.
  

As a member of Principal Health Care, you have the responsibility to:

• Read your Membership Handbook and Group Membership Agreement! You are subject to all of the terms, conditions, limitations and exclusions in the Agreement. You are also subject to all the rules and regulations of the Health Plan as detailed in both the Handbook and the Agreement.
  
• Always seek care through your primary care physician.
• Call Member Services and request reassignment if you wish to change your primary care physician. The change will take effect within thirty­one (31 ) days of your request. You may change your primary care physician no more than twice a year, unless extenuating circumstances exist.
  
• Obtain a referral and/or authorization from your primary care physician before receiving services from a specialist, hospital, or other provider. Remember, retroactive referrals are not covered.
  
• Always identify yourself as a Principal Health Care Member when calling for an appointment and when obtaining health care services.
  
• Always present your Principal Health Care identification card when obtaining health care services.
  
• Keep scheduled appointments or, if necessary, call to cancel appointments as early as possible. Remember, your primary care physician or participating provider may bill you if you fail to keep a scheduled appointment.
  
• Inform us of any additional health insurance your family may have so that payments can be properly coordinated between us and the other insurer.
  
• Cooperate with your health care professionals and follow their advice for treatment of injuries or illnesses.
  
• Know how to recognize an urgent care condition versus a medical emergency and what to do if one should occur.