Frequently Asked Questions About the Health Plans
Q: What Health Plans are offered?
A: Riverside Health System is pleased to offer the following three health plans for 2013:
- Riverside CareAdvantage PPO
- Anthem HealthKeepers HMO 25/30
- Lumenos High Deductible Health Plan (HDHP)
Q: When will I receive my 2013 health plan rates?
A: Health Plan Rates are available by logging in to Employee Self Service (ESS). Your Human Resources representative will also have the rates available.
Q: What preventive services are free?
A: You may find a list of preventive services that may be provided at no charge to you through network providers at: www.healthcare.gov/law/about/provisions/services/lists.html. These services include many screenings and immunizations.
Q: If a member is required to follow-up more frequently on an otherwise preventive service because of diagnosis or physician concern, for example, a mammogram or colonoscopy, is the service still covered at 100%?
A: Typically, when you have been diagnosed with a condition or have symptoms and/or a family health history, the service is no longer considered preventive and is not covered at 100%.
Q: Does Riverside offer employee discounts at Riverside providers and facilities on charges not covered by insurance?
A: All employees and eligible family members are eligible to receive a 25% discount on services at most Riverside providers. Hampton Roads Eye Associates does not participate in the 25% discount. M.D. Express offers 25% discount on copay only if employee badge is presented at time of service or within three days of service.
Q: Will Riverside continue the inpatient liability waiver up to $1,000 for special out-of-area situations?
A: Yes, employees and family members who are covered under any Riverside Health System group health plan may be eligible for partial waiver of the inpatient liability up to $1,000 if
1) they live or work in an area where no Riverside facilities are available;
2) an emergency admission is required while out of the Riverside service area;
3) there are no Riverside facilities able to treat a particular illness or condition; or
4) the Anthem physician in the area able to treat the illness or condition does not admit to a Riverside facility.
Other situations where the participant is unable to use an Riverside facility may be discussed in advance on an individual basis. To be considered for the Inpatient Deductible Waiver in an alternate facility, send a brief letter explaining your situation to Total Rewards/Benefits Services, through interoffice mail or fax at (757) 534-5550.
Q: Under the Riverside CareAdvantage PPO, at what labs can members get diagnostic lab draws?
A: The network for the Riverside CareAdvantage PPO does have participating labs in order to remain in-network, but there is not an exclusive arrangement with LabCorp like we have had under Anthem HealthKeepers HMO 25/30. The same applies to the Lumenos High Deductible Health Plan. To determine in-network labs, go to www.anthem.com. Select Find A Doctor >Select Virginia >KeyCare PPO >Select Hospitals, Facilities… >Select Laboratories. Enter the zip code and mile radius. The HealthKeepers HMO 25/30 will continue to require the use of LabCorp.
Q: Will a copay be required for Riverside Urgent Care at the time of service?
A: It will depend on the type of service. If it is considered a professional visit, then the co-pay will be based on whether the visit is primary care or specialist. Other services will be charged as co-insurance.
Q: On the Riverside CareAdvantage PPO plan, when it says for Riverside network "20% of the amount the health care providers in our network have agreed to accept for their services," what does that mean?
A: Here is an example that will demonstrate how this works. The 20% is based on the amount the provider agrees to accept; the "allowable amount" which is usually a percentage below their charges. "Allowable amount" is defined as the maximum fee that the health plan will reimburse a provider for a given service. So, for example, an office visit charged at $100 may have an "allowable" amount of $60 and the member would be responsible for 20% or $12.00. Allowable amounts may vary by procedure code used by the practice. This is just an example.
Q: What will I need to do to enroll in one of the 2013 plans?
A: You will make your health plan selection online during your 30 day eligibility period. It’s important that you review your choices for health plans and make your selection before you login to Employee Self Service/New Hire Enrollment to select your benefits.
A: A Health Maintenance Organization (HMO) is based on having a primary care physician who coordinates your health care. It is usually a smaller network and requires referrals to see a specialist. Typically, HMOs do not provide any benefits for services from a provider outside the network. A Preferred Provider Organization (PPO) provides benefits for services from both in-network and out-of-network providers. Typically, benefits are paid at a higher level for in-network providers. It does not require referrals to see a specialist. A PPO may have co-pays and/or co-insurance. Some services may have a deductible to meet before benefits are paid. Anthem’s PPO network is nationwide and much broader than their HMO network.
Q: I am selecting the Riverside CareAdvantage PPO plan for 2013. Why am I being asked to provide the name of my primary care provider during this online Open Enrollment process?
A: Riverside is asking you to provide the name of your “Primary Provider” for purposes of communication and reporting and to aid in managing your care into the future. A Primary Provider is required for Riverside team members, spouse, and children over the age of 18 if covered under the PPO. Having a Primary Provider can facilitate better access to health care, increase satisfaction with care, and ultimately improve health.
Q: My Primary Provider is not a member of Riverside Medical Group. Do I have to change physicians under the Riverside CareAdvantage PPO?
A: You do not have to change physicians, but you will pay the costs under the Anthem In-Network benefits or Out-of-Network benefits accordingly. You also will provide this physician’s name during online enrollment as your primary provider (medical home).
Q: What if I am located geographically in an area where the Riverside network has few providers?
A: You will need to compare the three health plans to determine which provider network and coverage choice best meets your needs. In areas where you find fewer Riverside providers, the HMO 25/30 could be a better choice.
Q: What are some other resources that team members can consider to meet their healthcare needs?
A: There are a number of services available in our area, including: FAMIS 1 (877) KIDSNOW, Medicare 1 (800) MEDICARE, Medicaid 1 (800) 432-5924, the Partnership for Prescription Assistance (PPA) 1 (888) 4PPA-NOW, Project CARE (757) 856-7100, and others.
Q: How can I find more information about each health plan?
A: All three of our health plans are offered through Anthem. More information is available at www.anthem.com and on the Total Rewards page of the Riverside Intranet. Prescription drug information for EnvisionRxOptions is available at www.envisionrx.com.