Q. What is the HMO service area?
A. The Florida service area consists of eleven counties: Dade, Broward, Hillsborough, Lee, Orange, Osceola, Palm Beach, 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 not be covered.

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 One Health Plan HMO or PPO 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.  The form is available on the HR website under HR Forms.

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.   Keep in mind that no matter where the dependent is, he/she will always have their Emergency Accident / Illness benefits. Non-emergency coverage on the HMO outside of the service area will not be covered.  Non-emergency care received outside of the network on the PPO is paid at 60% of the ACR after deductible.

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. 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 a 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 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 (PPO only).

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 there is no coverage on the HMO and 60% coverage after deductible on the PPO.

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

Q. If I have surgery in my doctor's office does the $200 copay on the HMO apply?
A. No, the physician office visit copay applies.  The $200 copay applies to surgery done in the hospital or surgery done in an outpatient facility.

Q. How is my mammogram covered ?
A.  On the HMO it is covered at 100%.  On the PPO it is covered at 90% after the $500 deductible.

Q. On the HMO $200 copay, does this apply to newborns and mothers separately?
A. Yes, because they are considered two separate patients.

Q. On the PPO, what does the $500 deductible apply to?
A. The deductible applies to anything that is not an office visit, prescription or emergency room visit.  This includes hospital, physical therapy, x-rays & labs (even if preventative) and everything else besides office visits and emergency room visits.

Q. What is the ACR and does it apply to the HMO?
A.  ACR is the average contracted rate.  It does not apply to the HMO-only out of network services on the PPO and POS.  The reimbursement for non-network services will be based on the average contracted rate of the network providers and not usual and customary rates (UCR).   This increases the patient out of pocket expenses by the difference in  UCR and the average discounted contract rate of a network provider.  Amounts over the ACR are never applied to the out of pocket maximum.  This means you will always pay for anything over the ACR, even if you have already hit your out of pocket maximum.  Read the ACR brochure for details.
 
 

Every attempt is being made to help you understand your benefits; however, any statements regarding coverage made by an Employee of the Plan Administrator or Great West will not be a guarantee of payment, only a description of benefits.  Actual benefit payment can only be determined at the time the claim and all related information is submitted  to the Great West.  All benefit payments are subject to the provisions of the Plan Document and Summary Plan Description in effect at the time services are rendered.