Q. What is the HMO service area?
A. The Florida service area consists of seven counties: Hillsborough, Orange, Osceola, Pasco, Pinellas, Polk, and Seminole. You must live or work in one of the seven counties to be a member of the HMO.

Q. Does the HMO plan pay for care received outside the service area?
A. The plan does pay for emergency services received outside the service area at the in network level of 100%.  The plan will not pay at the in-network level for non emergency care received outside the Florida service area. Any non emergency care received outside the service area will be considered out of network and paid at 70% after the deductible.

Q. With the switch in plans, what if I am currently seeing a specialist?
A. If you enroll in the HMO, you will need to contact your primary care physician before seeing the specialist in 2001. If the specialist is part of the network then only the referral to the specialist needs to be made. If the specialist is not part of the network, then you will be asked to transition your care to a specialist who is in network. On the PPO, you can continue seeing that specialist without a referral, but in order to receive the high level of benefits the physician needs to be part of the PPO network.

Q. What about my prescription refills?
A. At the retail pharmacy, you will not need a new prescription. You will just give the pharmacy your Great West plan information. For about the first month you may need to purchase your prescriptions up front and then submit a claim form to the Great West prescription service for reimbursement.

To fill through mail order, you will need to get a new prescription.

Q. Is there anything I can do if my doctor is not on the network?
A. You can ask the doctor to consider joining the Great West network. There is a form that you can take to your doctor and send back to Great West or have the doctor contact Great West directly at 1-800-663-8081.

Q. Do I need a referral to see a specialist?
A. If you are on the HMO you do need a referral to see a specialist. Referrals will be made within the PCP’s same Medical Group. On the PPO you do not.

Q. On the HMO, do I need a referral to an OB/GYN?
A. No, you can visit chiropractors, OB/GYN, Dermatologists, and podiatrists without referrals subject to the state mandated limitations.

Q. What about coverage for my dependent child who is going to school out of state?
A. Your dependent can be covered as long as they meet the eligibility requirements. The dependent will need to choose a PCP in the Florida Service Area and all routine care should be received from the Florida PCP, otherwise it will be considered at 70%. Keep in mind that no matter where the dependent is, he/she will always have their Emergency Accident / Illness benefits. Coverage on the HMO outside of the service area is considered out of network and paid at 70% after deductible.

On the PPO, if there is not a network provider in the area, coverage will be provided at 80% coinsurance instead of the 70% out of network.

Q. What if I am being treated at a facility that is not in the network, yet it is the only facility that offers the treatment?
A. On the HMO, your PCP would need to call Great West and a medical review would need to be done by One Health Plan and if Medical Management approves it will be paid at the 100% after the Hospital Copay on the HMO and 90% on the PPO. This is if there is no facility available, not if you choose to go to this facility and not another one.

Q. What is pre-certification?
A. Some services, such as hospital stays, surgery, physical therapy, etc. require pre-certification. This means your PCP or Specialist must call Great West to get an authorization before the treatment. When a provider calls to pre-cert and they are referring to a non-network facility, Member Services will advise the provider that they must be rendered at an in network provider to be paid in network. The member will then be redirected to a network facility.

Q. What if I see a non-network PCP and they refer me to an in network hospital?
A. If you are on the HMO all claims related to the hospital admission will be paid at 70% after the deductible.

If you are on the PPO plan, the physician will be paid at the 70% and the hospital will be paid at 90% and all other claims relate to the admission (such as lab, anesthesiologist, etc.) will be paid based on whether the provider is in or out of network.

On the PPO, if you use a network physician and hospital, all claims, including all other admission related claims, will be paid at 90%.

Q. Are pre-existing conditions covered?
A. Pre existing conditions are covered on the HMO. They are covered on the PPO if the member had prior coverage with no break in service for 12 months prior. If there is no prior coverage, pre existing are not covered for 3 months without treatment and one year after enrollment with treatment.

Q. Can I have an physician who specializes in Internal Medicine as my Primary Care Physician on the HMO?
A. Yes, you may have a Family Practitioner, General practice, or internal medicine as your primary care physician and a Pediatrician for the children.

Q. Does everyone in my family have to have the same PCP?
A. No, each person can have their own Primary Care Physician.

Q. Do I need to file claim forms?
A. You will not have to file claims for an in network provider on the HMO or PPO. However, you may need to file claims for any out of network providers and they may require that you pay in full at the time of service.

Q. What is the difference between out of area and out of network?
A. Out of area coverage only applies to the PPO and is anytime you are traveling and there are no network providers available in an area. Out of area coverage is at 80% on the PPO.  Out of network coverage on the PPO is anytime you choose to go to a provider that is not on the network.  Out of network coverage is at 70% after the deductible.

There is no out of area coverage on the HMO, only approved and non-approved services. Approved (in-network) services are any services your PCP provides you and any services/specialists that the PCP may refer you to within the network.   Non-approved (out of network) is anytime you choose a physician who is not on the network, or you do not receive PCP approval. Out of network/non-approved coverage is at 70% after the deductible.

Q. If I am traveling out of the country, am I covered?
A. Yes, you are always covered under the Emergency Accident & Illness benefit at 100% minus copay. If you are out of the country and receive non-emergency services you are covered on the out of network benefits of 70% coinsurance.

Q. Do the office visit and prescription drug copays apply to the individual out of pocket maximum?
A. Yes, It includes the office visit and the prescription drug copays.

Q. Is allergy testing covered?
A. Yes, on both plans.

Q. Does the in-network deductible on the PPO apply to emergency room visits?
A. Yes