The Health Care Program offers services for complex or chronic conditions to help you receive medically necessary treatment and avoid gaps in care. These services include but are 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.
- Treatment-plan review. Care Coordination can work with you and your health care providers to evaluate your options (including at-home services). Care Coordination may request your provider to periodically submit a treatment plan to Care Coordination for review.
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:
- Request preauthorization 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 health complications, patient safety issues, gaps in care, 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.