HMO POS PPO - Arkansas Blue Cross and Blue Shield

General Questions and AnswersQ: Do I need a referral for my annual gynecologistvisit and mammogram?A: No. Both are covered without a referral. Noreferral is ever required to an in-networkgynecologist.Q: What is covered under the Enhanced WellnessBenefit?A: For a complete list of preventive services thatare now covered 100%, visit www.arbenefits.organd look under the “Benefits Library” for theSummary Plan Description or you may callCustomer Service at 1-800-482-8416.Q: Do I need referrals if I’m under the POS plan?A: POS members, you have a choice. You canchoose to seek care in-network and follow the sameguidelines as the HMO members or you have theoption to go out-of-network or seek specialty carewithout a referral and pay an additional cost. Whenmedical care is obtained out-of-network, you areresponsible for the out-of-network deductible,copayment, coinsurance, and may also beresponsible for the difference between billedcharges and the Health Advantage allowed amount.Q: Does Health Advantage require preauthorizationfor services?A: Health Advantage only requires preauthorizationfor the following services:• Breast reduction (not related to cancer)• Enteral feeding• IDET• Out-of-network services• Swing bed care (pre-authorization fromCase Management)• Transplant (excluding kidney and cornea)Q: Are pre-existing conditions excluded?A: No. The State of Arkansas does not exclude preexistingconditions.Q: My Emergency Room (ER) claim was deniedfor not being an emergency. What is an emergency?A: An emergency is defined as traumatic bodilyinjury or sudden, unexpected onset of an illnesswhich requires immediate care and attention from aqualified physician, or when the condition, if nottreated immediately, could reasonably be expectedby a prudent layperson to result in serious physicalimpairment. When emergency services are needed,the member is to proceed as follows:1. Seek emergency care immediately at thenearest emergency facility.2. As soon as possible, notify your PCP ofyour emergency care, so that follow-up caremay be arranged.3. All follow-up care must be authorized by thePCP and rendered by an in-network providerin order for in-network benefits to apply.Q: How will the Any Willing Provider (AWP) lawaffect my coverage?A: AWP is an Arkansas law, so providers outsideArkansas will not be affected. In Arkansas, if aprovider applies to be a participating provider, andcompletes our credentialing process, then thatprovider will be part of the Health Advantagenetwork, and normal in-network benefits will apply.Providers will still have the choice whether or not toparticipate, so there may still be some providerswho will not be in-network. For the most accurateand up-to-date provider directory, please visitwww.HealthAdvantage-hmo.com.Q: May I remain with Health Advantage after myretirement? How will my coverage change?A: Yes, as a retiree under age 65 and not Medicareprimary, you may remain on this Health Advantageplan. Your copays, out-of-pocket maximums andbenefits (including a prescription drug card) willremain the same. Non-Medicare primary retireesalso have the option to move to the ARHealthbenefit plan. While the benefits will remain thesame, the premium amount, copays and out-ofpocketmaximums will change.Retirees over age 65 or Medicare primary retireeswill be automatically changed to the ARHealthbenefit plan administered by Health Advantage.More information is currently available on theHealth advantage Web site:www.HealthAdvantage-hmo.com