HMO plan guidelines

• The care you receive is covered by the plan's Medical Benefits (see Chapter 4 in the Evidence of Coverage).
• The care you receive is considered medically necessary. The services, supplies, or drugs are needed for the prevention, diagnosis or treatment of a medical condition and meet accepted standards of medical practice.
• You have a network primary care provider (PCP) who is providing and overseeing your care. As a member of our plan, you must choose a network PCP (see Chapter 3, Section 2.1 in the Evidence of Coverage).
  • In most situations, your network PCP must give you approval in advance before you can use other providers in the plan's network, such as in-patient hospitals and specialists, e.g. podiatrists and other health care professionals. This is called a "referral" (see Chapter 3, Section 2.3 of the Evidence of Coverage).
  • Referrals from your PCP are not required for emergency care or urgently needed care. For other types of care, you can receive without having approval in advance from your PCP, (see Chapter 3, Section 2.2 in the Evidence of Coverage).

• You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The health plan may consider exceptions to this in the following limited circumstances:

  • Emergency care: A medical emergency is a situation where you believe the medical symptoms require immediate medical attention to prevent loss of life, loss of a limb or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain or a medical condition that is quickly getting worse. Emergency care does not need PCP approval or a referral. In the event the physician providing the care determines the services were not an emergency, coverage may still be available if you reasonably thought your health was in serious danger (see Chapter 3, Section 3.1 in the Evidence of Coverage).
  • Urgently needed care: This is for treatment of a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. An example of an unforeseen condition could be an unexpected flare-up of a known condition. Out-of-network providers may furnish urgently needed care when network providers are temporarily unavailable or inaccessible. Examples of conditions, which would not be eligible for coverage when rendered by an out-of-network provider, include routine treatment, treatment for stable chronic conditions, acute minor illnesses (e.g., the common cold) or elective procedures (see Chapter 3, Section 3.2 in the Evidence of Coverage).
  • Medically necessary, covered services not available from a network provider: If providers in our network cannot provide a Medicare-covered, medically necessary service or treatment that is not urgent or emergent, you may receive care from an out-of-network provider. However, before you receive care from an out-of-network provider, your PCP must obtain authorization from the plan. If the plan gives authorization, it will only cover the specifically requested treatment for a designated period, or until the treatment is completed (see Chapter 3, Section 2.4 in the Evidence of Coverage).
  • Kidney dialysis services: Services may be provided at an out-of-network, Medicare-certified dialysis facility when you are temporarily outside the plan's service area (see Chapter 3, Section 2.4 in the Evidence of Coverage).

You may change your PCP for any reason, at any time. To change your PCP, visit our website at regence.com/medicare to make your PCP request. Refer to Find a Doctor to locate an in-network provider. If there is a particular plan specialist or hospital that you want to use, check first to be sure your PCP gives referrals to that specialist or uses that hospital.

• Step 1: Sign into your member account at regence.com/medicare
• Step 2: Select My Plan > Manage your account

• Step 3: From My account compose a request via Message Center with the details of the request. Use the topic: Change my primary care provider

Or you may contact Customer Service by phone or live chat.

Your request will be effective on the first day of the month following the date our plan receives your request. If you are seeing specialists or getting other covered services that needed your PCP's approval (such as specialist referrals) you will need your new PCP to contact us to update your referrals. You will also receive a new member ID card that shows the name of your new PCP.

For additional details, please see the Evidence of Coverage on the forms & documents page.