INNOVATIONS
PPO-LIKE PLANS
What
is a PPO?
PPO stands for Preferred Provider Organization. Simply put, this type
of plan extends higher levels of benefits when members choose to obtain
services from participating (preferred) providers. The Innovations PPO-like plans
extend higher levels of benefits when members use a participating providers.
How
does the Innovations plan work?
Members are able to seek medical care from any provider. For most services
members must satisfy a deductible before New West makes payment. The
exception is for physician office visits, urgent care, and preventive
visits. These benefits either extend a $20 copayment or waive the deductible
and apply coinsurance for the first 5 visits depending on the status
of the selected provider. When members select a participating provider,
they receive a higher level of benefits than they do when a non-participating
provider is selected. There are separate deductibles associated with
in and out-of-network services.
Are
all benefits subject to my deductible?
Depending on the Innovations plan selected by you and your employer,
some services such as physician office visits, accident benefits, and
preventive services benefits, mammograms, and well baby care may be
available without having to meet your deductible. Check your plan Outline
of Coverage to confirm the benefits associated with your plan.
How
is payment handled once my deductible is met?
Once your deductible is satisfied, you are responsible for the coinsurance
amount associated with your plan. You may also experience balance billing
if a non-participating provider is used.
When
does my deductible start over?
Your deductible is consistent with your group plan year.
How
does my ID card work?
Your ID card acts as your key to access the
system. You should carry your ID card at all times and show it to providers
when receiving health care services. The card includes important information
that will be helpful to you and your provider. Members who lose their
card or require additional copies for dependents should contact a Member
Services for replacement or additional copies.
What
are covered services?
Members are entitled to receive the Health Care Services specified in
the selected Outline of Coverage and Member Certificate if all of the
following requirements are satisfied:
• The health
care services are medically necessary;
• The member has been properly enrolled;
• The Premium for the member has been paid;
• The member has satisfied the applicable deductible and coinsurance
amounts;
• Precertification, if necessary is received from New West Health
Services; and
• No exclusion or limitation applies to the health care services.
Does
my deductible apply to my maximum out-of-pocket?
Covered services received from providers are subject to the deductible
and coinsurance specified in the Outline of Coverage. The out-of-pocket
maximum includes the plan deductible.
What
are my payment responsibilities?
Members may be required to submit payment in full to Providers at the
time Health Care Services are rendered. If a Member pays amounts above
the applicable Deductible and Coinsurance for Covered Services, the
Member may submit a claim for Reimbursement directly to New West. Please
note that claims for Reimbursement Benefits must be submitted to New
West Health Services within one year of the date that the Health Care
Services were rendered.
In addition to applicable
Deductible and Coinsurance obligations, Members may be balance billed
for non-participating provider charges that are above the New West Usual,
Customary and Reasonable amount. Members are also responsible for services
rendered that are not Medically Necessary or Covered Services as described
in the Member Certificate.
How
do emergency health services work?
In an Emergency, a Member should call 911 or go directly to the nearest
Hospital emergency room or medical facility for treatment. "Emergency
Health Care Services" are Medically Necessary health care procedures,
treatments or services delivered to a Member after the sudden onset
of what reasonably appears to be a medical condition that manifests
itself by symptoms of sudden severity, including severe pain, so that
the absence of immediate medical attention could reasonably be expected
by a reasonable layperson to result in:
• Serious jeopardy
to a Member's health; or
• Serious impairment of a Member's bodily functions; or
• Serious dysfunction of any bodily organ or part of a Member;
or
• Disfigurement to a Member.
Emergency Health
Care Services are subject to the Deductible and Coinsurance as specified
in the Outline of Coverage.
Members must notify
a New West Health Services Patient Care Coordinator of an Emergency
Room visit within 48 hours of treatment, or as soon as is reasonably
possible thereafter.
If New West Health
Services determines, based on generally accepted medical criteria, that
Health Care Services or supplies were not Emergency Health Care Services,
then such Health Care Services or supplies may not be Covered by New
West Health Services and the cost of such services shall be the Member's
responsibility. However, New West Health Services shall not deny reimbursement
for Emergency services claims if the Member possesses average knowledge
of health and medicine and in good faith seeks medical care for what
reasonably appears to the Member to be an acute condition that requires
immediate medical attention, even if the Member's condition is subsequently
determined not to be an Emergency.
