HMO Benefit Summary

HMOs typically provide a wide range of preventive and maintenance health care services. Non-diagnostic services such as physical examinations, pap tests, mammography screenings, PSA tests, immunizations and others are commonly covered by HMOs.

All health plans that serve State of Ohio employees must provide, at a minimum, the following services:

Mental Health
A comprehensive range of mental health benefits are provided by United Behavioral Health (UBH). See the Mental Health section of this book for details.

Prescription Benefits
In addition to those medical services listed above, all HMOs provide prescription benefits to their members. All HMOs provide a retail pharmacy plan, and a voluntary mail-order plan.

Effective July 1, 2007, all health plans will receive the services of a single pharmacy benefit manager (PBM) - Catalyst Rx - and a single preferred drug list to assure consistent service and help control costs. A preferred drug list is an approved list of medications which HMO network physicians may prescribe.

Retail prescription benefits have the same copay structure for all health plans. You pay $10 per prescription for generic medications; $22 per prescription for preferred brand-name medications; $44 per prescription for non-preferred brand-name medications (when generic is not available) and $44 plus the difference in cost between the brand name drug and generic drug for any non-preferred brand-name drug that has a generic equivalent.

The following copays for a 90-day supply of drugs through the mail-order prescription plan apply. You pay $25 per prescription for generic medications; $55 per prescription for preferred brand-name medications; $110 per prescription for non-preferred brand-name medications (when generic is not available) and $110 plus the difference in cost between the brand name medication and generic medication for any non-preferred brand-name medication that has a generic equivalent.

Prescription Medication Exclusions. Refer to the Catalyst Rx Web site or call their customer service department at 1-866-854-8850.

Health Management Program (Take Charge! Live Well!)
Programs available to all employees enrolled in a state health plan and their eligible dependents to help members live a healthy lifestyle. Programs include health assessments, telephone coaching, online lifestyle behavior change programs, online and print health information, condition management, worksite health screens, nurse advice line and preventive care reminders. Some programs may include a financial incentive for participants.

Condition Management
These programs provide education and support for patients to assist in the self-management of chronic conditions, including asthma, cancer, chronic obstructive pulmonary disease, congestive heart failure, diabetes, obesity, renal disease, end stage renal disease and severe lower back pain.

Diabetes supplies and durable medical equipment (including insulin pumps where medically necessary) are covered at 100 percent with no deductible, copayment or coinsurance upon participation in the diabetes condition management program.

Call the following providers for more information and to be enrolled in the appropriate program:

HMO Customer Service Phone Numbers
See Customer Service Phone Numbers for HMO phone numbers and other important contact information.

Payment for Services
HMOs require you to pay a coinsurance of 20% when you obtain services. Check with the HMO to determine their policies or review the most current Benefits Comparison Chart and Guide. If coinsurance is required, the HMO cannot require any state employee to pay more than a specific amount out-of-pocket in any benefit period (generally 12 months). This is called the out-of-pocket maximum. A person enrolled in an individual contract has a $1,000 out-of-pocket maximum and a family policy has a $2,000 out-of-pocket maximum.

Some HMOs require the enrollee to pay a small fee, a copay, for some services, such as an office visit or emergency room visit.

Some HMOs will “cap” certain services and will pay for no more in a benefit period than a specified amount. For example, an HMO may allow $2,000 in a benefit period for physical therapy services. Once the cap is reached, the HMO will pay no more toward physical therapy service in that benefit period.

HMOs typically do not require the enrollee to complete a claim form when services are received. Some HMOs may provide an explanation of benefits received following treatment.

Claims Appeal
Each HMO has its own procedure for appealing a claim decision which you believe was made in error. Look in the benefit book provided by the HMO or call the HMO’s customer service number for more information.

Out-of-Pocket Maximum
The out-of-pocket maximum is the total amount you must pay out of your own pocket before your plan covers your medical expenses at 100% for the plan year. The out-of-pocket maximum offers financial protection by limiting the total amount you must pay toward health care services. Once your copays reach the out-of-pocket maximum amount, the plan will pay 100% for the balance of the benefit year. There is no limit to the amount an HMO will pay per year, except in the case of human organ transplants which are limited to $1 million in a lifetime. Some expenses are not applied to the out-of-pocket maximum. Expenses for products or services not covered by an HMO or which are not medically necessary are not included, nor are any penalties you must pay.

Your Identification Card
If you do not receive your identification card within two weeks of enrolling, contact the plan. Always carry your ID card with you. This card also may be used for the plan’s prescription drug program and mental health services through United Behavioral Health.

If you require medical service or prescriptions, and have not yet received or have lost your ID card, call the HMO’s customer service unit. They will verify your enrollment for providers and send you a new or replacement card.

Standards of Quality
All HMOs for state employees must provide core benefits and must meet certain negotiated minimum standards to safeguard their interests and those of their patients. The standards include the following:

NCQA
In addition, all HMOs available to state employees must be accredited by the National Committee for Quality Assurance (NCQA). To obtain NCQA accreditation, HMOs are examined according to standards that evaluate how well a health plan manages all parts of its delivery system in order to continuously improve health care for its members. Accreditation assures members that their HMO is proficient and constantly improving in important categories related to the delivery of quality health care benefits.