Health care services that are not coordinated between providers may lead to gaps in care, patient safety issues, health complications, or misuse or overutilization of resources, especially for patients with complex or chronic conditions. The Health Care Program offers Care Coordination services, including but not limited to:
- Making arrangements for health care services for your complex condition. Care Coordination can assist you in locating doctors, hospitals, and other providers; arrange for Durable Medical Equipment or other services or supplies; and provide assistance related to the Plan’s Travel Benefit.
- Provider coordination. Care Coordination can work with you and your physician to coordinate your specialists, pharmacists, hospital, and other providers.
- Care plan assistance. A “care plan” or “treatment plan” is an important tool that can help you and your providers coordinate your care. If you do not have a care plan, a specially trained nurse on the Plan's Care Coordination staff can help you work with your providers to organize a plan that reflects the treatments and goals that you and your providers decide on together.
Although Care Coordination is intended to help you have a better health care experience, the Health Care Program and the participating employers are not health care providers, nor do they guarantee positive health outcomes, avoidance of complications, or avoidance of gaps in care.
To learn more about Care Coordination, call Member Services at (855) 979-5192 and ask to speak with a Care Coordination nurse.
Benefit Penalty for Declining Care Coordination
In some cases, the Plan may determine that Care Coordination is required when you:
- Have a preauthorization request for services related to a complex or chronic condition (for example, cancer treatment, dialysis, or cardiothoracic surgery),
- Incur claims related to a complex or chronic condition,
- Fail to complete a prescribed course of treatment, or leave a health care facility against medical advice or against therapist's advice,
- Receive home-health services,
- Receive treatment involving three or more inpatient stays, or 30 or more inpatient days, within the preceding 12-month period, or
- Receive services or supplies that the Plan determines may be contributing to gaps in care, patient safety issues, health complications, or misuse or overutilization of resources.
If the Plan determines that Care Coordination is required, the Plan will notify you in writing. If you decline to utilize or cooperate with Care Coordination, the Plan may impose a benefit penalty equal to 40% of the amount the Plan would normally pay with respect to expenses related to the requirement. This benefit penalty does not apply toward any deductibles or out-of-pocket limits.
It is the Plan’s expectation that treatment of a complex or chronic condition will follow a treatment plan. Care Coordination can help members work with their providers to develop a treatment plan. The Plan may require you or your provider to periodically submit a treatment plan to Care Coordination for review. A member’s failure to obtain or adhere to a treatment plan can be considered a failure to utilize or cooperate with Care Coordination and result in the Plan’s imposition of the 40% benefit penalty described above as well as a review of exclusions that may apply as described in “Definition of Medical Necessity.”