The amount the member must pay for medical services (doctor visits, drug prescriptions, hospitalizations, etc.).
A Primary Care Physician can be a family practitioner, internist, or pediatrician. At the time of enrollment, you may have selected (or been assigned) a Primary Care Physician for yourself and each dependent. The Primary Care Physician coordinates all health care and medical needs, including basic care, preventive services, referrals to specialists, and hospitalization arrangements.
Can each family member select a different Primary Care Physician?
Yes, each family member may choose a different Primary Care Physician who is best suited to his or her needs (i.e., the employee and spouse may want to select a general practitioner, while selecting a pediatrician for their dependent children).
Yes; contact your Health Plan’s Member Services Department using the phone number on your medical ID card. Plans may allow you to change your PCP through their website (some restrictions may apply).
Under the HMO plans, your Primary Care Physician, in consultation with a contracted Medical Group or IPA, will determine the proper treatment and make referrals to specialists when necessary. A change in Primary Care Physician or HealthPlan could cause a problem if you are in the middle of specialist treatment.
The member should present his or her welcome letter, which highlights benefit coverage; to the Primary Care Physician selected for services. The physician’s office may then contact the insurance company to assist with verifying coverage.
The member should make sure the pharmacy he or she wish to use works with Their HealthPlan. The member will need to pay the full amount of the prescription up-front but may request reimbursement by retaining the paid receipt and contacting the Health Plan’s Member Services Department.
In the event of any emergency, contact your Primary Care Physician first. Depending on the nature of the emergency, your physician will either: help over the phone; make an appointment for you to come in as soon as possible; or make a referral to an emergency room or urgent care facility. If the emergency is life-threatening, such as a heart attack, or is critically serious, such as a broken leg, go directly to the nearest medical facility. However, you (or a family member) must contact your Primary Care Physician within 24 hours. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan’s Member Services Department on your ID card.
If you are away from home and cannot see your Primary Care Physician, you will only be covered for emergency treatment that is medically necessary. Contact your Primary Care Physician first to obtain authorization. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan’s Member Services Department on your ID card. We suggest buying Travelers insurance If you are out of the United States.
Below is a list of the most commonly encountered qualifying/triggering events. These events trigger a Special Enrollment Period, during which an employee or dependent may make a change to their enrollment during the coverage year. Involuntary loss of minimum essential coverage (including, but not limited to, the following examples: loss of other employer coverage, loss of COBRA due to exhaustion, etc.) Marriage/Domestic Partnership Birth/Adoption/Legal Guardianship/Eligible Dependent Child Court Order Moving out of coverage area Return from active duty from Military or California National Guard Release from Incarceration Enrollment or plan change once a month due to Native American status
COBRA (Federal) and Cal-COBRA (State) laws allow for continuation of group Health benefits to individuals who lose coverage as a result of certain qualifying/triggering events” (e.g. termination of employment, death of employee, reduction of work hours, divorce, legal separation, Medicare entitlement, and loss of dependent child status)