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Referrals new in 2020 for Health Advantage Medi-Pak® Advantage HMO

Primary care physician (PCP) referrals are a proven way to help ensure members get the right care in the right setting and avoid unnecessary medical tests and services – and they’re new for 2020 for Health Advantage Medi-Pak® Advantage HMO (health maintenance organization) members.

As of January 1, 2020, Medi-Pak® Advantage HMO members must have a referral from their primary care physician before receiving services from a specialist. Please be sure to keep this in mind when explaining the product to clients/prospects.

We have developed a referral process that is one of the least restrictive around. It will be quite easy for healthcare providers to follow and will place little, if any, added burden on members. However, to avoid any confusion and/or frustration, members should be made aware that if they choose to see a specialist without a referral from their PCP, they may not be getting the maximum value from their coverage.

When are PCP referrals required?

Referrals are required for all specialists (virtually all providers/facilities other than the member’s PCP). This also includes:

  • Home health
  • Mental health
  • Occupational, physical and/or speech therapy performed in an office setting
  • Outpatient hospital facilities and ambulatory surgery centers

When are PCP referrals not required?

Services that do not require a referral include:

  • Urgently needed services (in network or out of network)
  • Emergency services (in network or out of network)
  • Temporary dialysis services from a Medicare-certified dialysis facility outside the plan’s service area
  • Routine women’s healthcare performed by an in-network provider:
    • Breast exams
    • Screening mammography
    • Pap tests
    • Pelvic exams
  • Preventative services performed by an in-network provider
  • Supplemental benefits: dental and hearing.

What do members have to do?

The member’s responsibility is very minimal. First, they must designate a PCP. After that, they just need to be mindful of the referral requirement and have clear communication with their PCP to be sure the process is followed. The PCP takes care of the rest.

Do members need to identify a PCP at enrollment?

Members are strongly encouraged to identify a PCP when they enroll. Collecting and entering PCP information at the time of enrollment reduces member confusion later on. It also allows agents to explain to the enrolling member the advantages of designating a PCP.

What happens if members do not identify a PCP at enrollment?

If members do not enter a PCP at the time of enrollment, Health Advantage will reach out to the member to request a PCP designation. Members who are not prepared to identify a PCP at enrollment or later wish to change a PCP designation also may call the customer service number on the back of their member ID card at any time and designate a PCP.

If members need further education about the role of the PCP and how it benefits them – helping them better manage their own health and get maximum benefit from their health coverage – we have developed a linked document called “What is a Primary Care Physician? Why do I need one?” for you to use and/or share with members who have questions.

We greatly appreciate your commitment to help your clients and prospects find the health plan that best fits their needs and preferences and hope you will find this information helpful as you assist them in that effort.