Medical Health Management Organization (HMO)
What is an HMO?
An HMO is a group of providers associated with or contracted by a medical insurance administrator. These providers include physicians, hospitals, pharmacies and laboratories. All non-emergency treatment must be received by one of these providers. Provider directories for each HMO offered by Santa Clara University are available in the Human Resources Office.
Which HMO's are available at Santa Clara University?
Kaiser Permanente and Blue Cross.
What type of HMO is Kaiser?
Kaiser is an HMO which owns its medical facilities and employs its own providers (i.e. physicians, nurses, lab technicians etc.) Kaiser offers full-service facilities which includes a hospital, physician's offices, pharmacy and lab. The closest full facility to SCU is about 15 minutes from campus.
What type of HMO is Blue Cross?
Blue Cross is an administrator that has contracted with private practicing physicians, medical groups, hospitals, pharmacies and laboratories. A physician you are currently using may be part of the Blue Cross network. For the most current provider network listing, visit Blue Cross' website at www.bluecrossca.com.
What is a Primary Care Physician (PCP)?
A Primary Care Physician is your primary doctor. This doctor coordinates all of your care. Therefore, specialty care must be referred by your PCP. A PCP is defined as an internist, general practitioner, family practitioner and pediatrician.
When do I choose my PCP?
With Blue Cross you must choose a PCP at the time you enroll in the medical plan. You may change your PCP at any time by contacting Blue Cross through their website or by calling the Member Services department. Kaiser does not require the selection of a PCP at the time of enrollment.
When Can a Specialist's Services be Obtained?
Specialist care must be referred by your PCP. Exceptions: Blue Cross and Kaiser allow self referral to a contracted OB/GYN for all women's health related symptoms and treatment, including the annual well woman exam. Both Blue Cross and Kaiser allow self referral to a contracted chiropractor.
Does Blue Cross require that the Specialist be contracted with the same medical group as the PCP?
Yes. Please check with your PCP for details.
Are there any limitations to the plans available based on where I live?
Most of the plans have a designated service area in which you must reside to be eligible for the plan. Check with the insurance carrier for service area restrictions.
Preferred Provider Organization (PPO)
What is a Preferred Provider Organization (PPO)?
A delivery system where providers are under contract to a carrier to provide care at a discount for a fixed fee, and the health provider provides incentives to patients to use the contracting providers. Employees can reduce their annual deductible, and the portion of the medical bill they pay, by selecting providers from a specific network of physicians and or facilities.
What does Network mean?
The doctors, clinics, hospitals and other medical providers that a carrier contracts with to provide health care to its covered persons at discounted rates.
What does "In-network" mean?
When the participants choose to receive care from providers who participate in a network under the plan, this is considered receiving care "in-network." Some plans have a "gatekeeper" who must authorize all care to have that care covered at innetwork levels under the plan.
What is an Individual deductible?
The dollar amount or "deductible" that an employee must pay for covered services before the insurance pays.
What is a Lifetime Maximum?
The maximum amount the plan will pay toward a member's coverage during the employee's lifetime.
What is an Out-of-pocket maximum?
The maximum amount that a covered person must pay for medical expenses covered under the plan. It is the sum of deductibles, co-payments or coinsurance. Some charges do not count toward this maximum.
What is reasonable and customary?
The amount customarily charged for the service by physicians in the area and the reasonable cost of services for a given patient after medical review of the services.
For policy questions, employees can consult the Staff Policy Manual FAQ page.