Employee FAQ

WHAT ARE SOME OF THE BENEFITS OF AN HMO?
One of the important benefits that an HMO provides is preventative care. Identifying small problems before they become serious ones. There is also no charge for periodic physical exams after the office co-payment. Annual well-woman gyn exams, routine immunizations and well-child care are also covered.

WHAT IF I NEED TO GO TO THE HOSPITAL?
Your primary care physician arranges for your care at a HMO hospital. All pre-authorized and covered hospitalizations, including medical procedures, cost of room, physicians and nursing services are included.

WHAT ABOUT EMERGENCY CARE?
A medical emergency is generally defined as the sudden or unexpected occurrence of a condition requiring immediate medical or surgical care to alleviate pain, suffering or life threatening situations. If one of these situations arises, you should seek care at the nearest emergency room and then notify your PCP as soon as possible. If the situation is urgent rather than emergent, you should contact your PCP before seeking care on your own.

WHAT THINGS ARE NORMALLY CONSIDERED EMERGENCIES?
It is usually an emergency if there is uncontrolled bleeding, serious head or other immobilizing injuries, severe burns, multiple traumas, onset of shock, no discernible breathing, loss of consciousness, drug overdose or poisoning.

WHAT THINGS ARE NORMALLY CONSIDERED URGENT?
Examples of urgent care situations are minor burns and infections, possible fractures, nausea and vomiting that do not respond to over the counter medications.

CAN I CALL AN AMBULANCE?
An HMO member is authorized to use an emergency medical transport when the member requires immediate transport to a hospital emergency room. Ambulance use for other than this reason is not considered a covered benefit and the member will be responsible for the bill.

WHAT IF I NEED CARE AFTER HOURS?
If your medical condition is not a sudden emergency you should still call your PCP for a referral to an appropriate treatment facility.

WILL I HAVE COVERAGE IF I AM AWAY FROM HOME?
Healthcare received outside of the HMO’s service area will only be covered if it is an acute, unexpected illness or injury, immediate medical attention was required and medical care could not safely be postponed until the member returned to the service area.

CAN I ADD OTHER MEMBERS OF MY FAMILY LATER?
If you already have family coverage you can add a new dependent at birth. If you declined family coverage you can only add it at the next open enrollment unless you have had a change in family status such as marriage or divorce.

HOW WILL I KNOW WHO THE DOCTORS ARE THAT I CAN CHOOSE FROM?
A provider list is available from your Human Resources Department and on this web site.

CAN I CHANGE DOCTORS IF I DON’T LIKE THE ONE I CHOSE?
Yes, but not more than twice per year.

IF I’M ALSO COVERED BY MY SPOUSE’S INSURANCE, WHICH PLAN WILL PAY FIRST?
Your plan will be primary for you. Children’s primary coverage is based on the earliest birthdate of the parents.

WHAT ARE EXAMPLES OF SERVICES THAT ARE NOT COVERED UNDER THE HMO?

Services that are not medically necessary
Cosmetic surgery or treatments
Dental Work
Sterilization reversal
Surrogate mother maternity expenses
Hearing aids or devices