HealthPartners HMO - Questions & Answers

I like my current doctor. Can I continue to see him or her under either of these plans?

Under the HealthPartners plan, you receive care through an extensive network of physicians, hospitals and clinics. When you join the HealthPartners plan, you must select a primary care clinic for you and each covered member of your family. You will receive the majority of health care services through this clinic. Because the network is extensive, there is a good chance that your current doctor is included. Check the provider directory at http://www.healthpartners.com/. If your doctor is not part of the network and that is an important aspect in choosing your coverage, you may want to consider the BlueCard PPO plan where you can see any doctor you choose. However, keep in mind that if your doctor is out-of-network under BlueCard, you will receive a lower level of coverage.

Where can I find a list of providers for my plan?

When you enroll in HealthPartners, you will receive a directory of providers. You can also call Member Services at (952) 883-5000 or 1-800-883-2177 or go on-line to http://www.healthpartners.com.

Am I covered by my plan when I travel internationally?

As you know, you must coordinate care with your primary care clinic in order to receive plan benefits. There are some exceptions for emergencies when you are outside an area where you can receive network care. Before you travel, speak with a provider at your primary care clinic or call Member Services at (952) 883-5000 or 1-800-883-2177.

If I choose to visit a provider outside my plan's network, how do I file a claim?

If you visit a provider outside the HealthPartners network, you will need prior authorization or a referral from a provider at your primary care clinic. If you do not receive prior approval, you will most likely not qualify for any benefits. There are some exceptions for emergencies. For more information, contact Member Services at (952) 883-5000 or 1-800-883-2177.

What does "usual and customary" mean?

"Usual and customary" is a guideline that insurance companies use to determine how much of a medical expense the plan will consider for coverage. A "usual" fee is the charge made for a given service by a doctor to the majority of his or her patients. A "customary" fee is one that is charged by the majority of doctors within a community for the same services. Generally, only charges for expenses up to the usual and customary level are eligible for consideration for coverage by a medical plan. Usual and customary considerations usually do not apply to services from network providers, because these providers charge fees according to negotiated rate agreements. However, usual and customary considerations are generally applied to out-of-network services if covered by your plan.

Do I need to select a primary care physician with my plan?

Do I need a referral to see a specialist?When you join the HealthPartners plan, you must select a primary care clinic for you and each covered member of your family. You will receive the majority of health care services through this clinic. If you have a health care need that cannot be handled at your clinic, a provider at your clinic will refer you to another provider within your care network. You may change your primary care clinic at any time during by calling HealthPartners with your new clinic number. To ensure coverage, always speak with a provider at your primary care clinic prior to receiving care from an outside provider or specialist.

What is a deductible?

A deductible is the amount of expenses for eligible services that you must pay out of pocket before the plan begins to pay benefits. There is no deductible under the HealthPartners HMO plan for care from network providers.

What is an out-of-pocket maximum?

"Out-of-pocket" refers to the expenses you pay for services, coinsurance, and deductibles (but not insurance premiums). Plan maximums are the most you'll pay in "out-of-pocket" costs in a single plan year. If you face very high medical expenses during the plan year, thanks to the out-of-pocket maximum, your share of the costs will not exceed $3,000 for care per person or $5,000 for care per family regardless of the number of dependents covered.

Will I receive a medical ID card?

You will receive a medical ID card for the HealthPartners HMO plan. When you visit your primary care clinic, you may be asked to present your card. It is important to present your card at participating pharmacies to obtain the highest level of benefits. Call Member Services at (952) 883-5000 or 1-800-883-2177 for more information.

What coverage is available through my plan for prescription drugs?

When you present your ID card at a participating pharmacy you will receive formulary drugs (up to 30 day supply), oral contraceptives (per cycle), and tobacco cessation (up to 30-day supply) for an $12 copay. You can also order prescriptions through HealthPartners Mail Order Pharmacy for a $24 copay (up to 90-day supply).

Does my medical plan provide any dental coverage?

Dental treatment to restore damage done to sound, natural teeth as a result of accidental injury is covered at 80% through the HealthPartners plan. If a non-plan provider provides care there is an additional $50 deductible, then coverage is 80% up to a $300 maximum. Preventive care for children age 2-19 is covered at 100% for x-rays, exams, cleaning, and fluoride treatment. Preventive coverage and additional dental coverage is available through the eFunds dental plan.

Who do I call if I have questions about my medical coverage?

There are a few different ways to find answers to your questions about medical coverage. When you enroll in the HealthPartners HMO plan, you will receive information booklets about the plan. You can also go on line to http://www.healthpartners.com/or contact Member Services at (952) 883-5000 or 1-800-883-2177.

Can I change my medical coverage during the plan year?

You may only change your medical coverage during the plan year if you experience a change in family status. If you experience a change in family status and wish to change your medical coverage, you must complete the Family Status Change form under the Froms link in eServe. You must make any changes to your medical coverage resulting from your change in family status within 31 days. Changes in family status include:

• Marriage
• Divorce or legal separation
• Birth or adoption of a child
• Dependent child's loss of eligible dependent status under the plan
• Death of your spouse or a dependent
• Change of employment status for you or your spouse
• Change in place of residence or worksite
• Qualified Medical Child Support Order (QMCSO)
• Entitlement to Medicare or medical benefits

Proof of these events is required and should be attached to the Family Status Change Form. Examples of proof are:

• a copy of a birth certificate or adoption placement paperwork for a new dependent child
• a copy of a marriage license for a marriage
• a copy of the divorce decree for a divorce, etc.

If you have questions about proper supporting documentation, please email Benefits@eFunds.com. These changes must be consistent with the event. Example: If you are covered under a spouse's insurance plan, and you are enrolled in the medical and dental options, and that coverage is lost, you can only elect medical and dental coverage under the eFunds plan. If you experience a change in family status and wish to change your benefits, you must complete the Family Status Change form located under the Forms link in eServe. You must make any benefit changes resulting from a change in family status within 31 days of the event.

Can I waive medical coverage?

You may waive medical coverage. You will receive the eFunds waiver reimbursement only if you provide confirmation of existing coverage elsewhere, e.g., through a spouse's dental plan. Confirmation of existing coverage must be sent to the Benefits Department on letterhead from the employer /or a copy of the current ID card from the company providing coverage. If you waive coverage, you will not be eligible for eFunds coverage until the next annual enrollment unless you experience a change in family status, as defined above. If you experience a change in family status and wish to change your benefits, you must complete the Family Status Change form located under the Forms link in eServe. You must make any benefit changes resulting from a change in family status within 31 days from the date of the event.