Learn answers to your questions
Hometown Health Plan (HMO)

Q. What is an HMO? Q. Who is eligible for coverage? Q. How do I apply for coverage? Q. What is my deductible for medical services? Q. Do I have to fill out a claim form? What should I do if I receive a bill? Q. What is my coinsurance (the percentage that I pay)? Q. What is my lifetime maximum? Q. What if the charges are higher than "usual and customary"? Q. How are prescriptions covered? Q. I'm leaving for a two-week vacation, and my prescription will run out before I return. What can I do? Q. How can I replace my lost Hometown Health membership card? Q. I will be moving soon. How do I notify Hometown Health Plan of my new address? Q. Am I required to select a Primary Care Physician? Q. What is the role of my Primary Care Physician? Q. I don't know any of the doctors on your provider list. What should I do? Q. Can my spouse and children have a different Primary Care Physician than I have? Q. Is my Primary Care Physician given any incentive NOT to send me to a specialist or NOT to provide me with appropriate care? Q. Do I need a referral for specialty care? Q. What is the role of a specialty care physician? Q. Does Hometown Health Plan cover physicals? Q. I'd like to see a chiropractor or seek alternative medicine. Does Hometown Health Plan cover that? Q. Whom do I call with an out-of-area emergency?

Hometown Health Plan (HMO) Answers to Your Questions Q. What is an HMO? A. HMO stands for Health Maintenance Organization. Hometown Health Plan contracts with doctors and other providers. You select from among these providers to receive authorized medical care. Present your Hometown Health membership card, and all you pay is your copayment, if applicable, for the services you receive. Hometown Health Plan pays the remainder of the bill. Back to top Q. Who is eligible for coverage? A. Employees and their dependents who meet their employer's eligibility guidelines and the guidelines defined in the Hometown Health Evidence of Coverage (EOC) booklet are eligible for health care coverage. Back to top Q. How do I apply for coverage? A. Fill out all sections, sign, and date your "Hometown Health Enrollment/Change Form" and return it to your employer. If you or your dependents do not apply when first eligible, you or your dependents or both may enroll at your group's next open enrollment or, if applicable, during the plan year if a change in life status occurs. See your employer for details. Back to top Q. What is my deductible for medical services? A. There is no deductible; you pay only your applicable copayment. Back to top Q. Do I have to fill out a claim form? What should I do if I receive a bill? A. You do not have to fill out any claim forms for care received from authorized and participating providers. The only bills for which you are responsible are your copayments or bills for unauthorized services acquired from a nonparticipating provider. If you receive a bill for which you believe you are not responsible, send it to Hometown Health Plan to process. Back to top Q. What is my coinsurance (the percentage that I pay)? A. There is no coinsurance; you pay only your applicable copayment (see your Summary of Benefits booklet or Attachment A - Copayment Schedule). Back to top Q. What is my lifetime maximum? A. Some benefits have lifetime maximums. See your Summary of Benefits, Attachment A, and Evidence of Coverage for limitations. Back to top Q. What if the charges are higher than "usual and customary"? A. You do not have to be concerned about "usual and customary" charges with this HMO coverage. You pay only your applicable copayment for covered services. Back to top Q. How are prescriptions covered? A. If Hometown Health Plan provides your prescription benefit, you must have a participating pharmacy fill your prescriptions (refer to your Provider Directory). The pharmacy will fill prescriptions to the amount prescribed but never to exceed a 30-day supply. Since Hometown Health Plan uses a formulary (a list of approved medications), your prescribed medication must be on the formulary to be covered. For formulary generic drugs, you will pay a low copayment per prescription. You will have to pay a slightly higher copayment for a formulary brand-name drug that does not have a generic-drug equivalent. For a formulary brand-name drug that has an approved generic-equivalent drug on the formulary, you will pay the brand-name copayment amount plus the difference in cost between the generic drug and the brand-name drug. For prescriptions that you need to take for more than a 90-day period, Hometown Health Plan offers a Mail Order Prescription Drug Program that can deliver your prescriptions right to your home. For more information refer to your Prescription Drug Rider or contact Hometown Health's Customer Services Department. Back to top Q. I'm leaving for a two-week vacation, and my prescription will run out before I return. What can I do? A. Your pharmacist may contact our Pharmacy Prior Authorization Line to request a special authorization number. With that number, the pharmacist will fill your prescription. Back to top

Q. How can I replace my lost Hometown Health ID card? A. You can request a new membership card by calling our Customer Services Department at 775-982-3232, option 2, or 800-336-0123, option 2. Hometown Health will send a replacement card to your home address within five working days of your request. Back to top Q. I will be moving soon. How do I notify Hometown Health Plan of my new address? A. Hometown Health Plan must have your correct address and telephone number. Please fill out an "Hometown Health Enrollment Application / Membership Change Form" at your human resources department, call our Customer Services Department before you move, or mail us a change of address card (available at your local post office). Note: If you move outside our service area, your coverage could be terminated. Back to top Q. Am I required to select a Primary Care Physician? A. Yes. If you do not indicate a Primary Care Physician, we will select one for you. You always retain the right to change your Primary Care Physician. If you notify us by the 25th of any month, we will change your Primary Care Physician effective the first of the next month. Back to top Q. What is the role of my Primary Care Physician? A. Your Primary Care Physician's primary responsibility is to provide, arrange, and coordinate all aspects of your health care. Back to top Q. I don't know any of the doctors on your provider list. What should I do? A. Our Customer Services Representatives will verify which providers are currently accepting new patients and provide you with some basic information, such as the type of practice, location, office setting (clinic vs. private practice), and appointment procedures. You can also call the 24-hour Health Hotline at 775-982-5757 or 888-324-3243. Back to top Q. Can my spouse and children have a different Primary Care Physician than I have? A. Yes. Each member may have his or her own Primary Care Physician. A general or family practitioner, internist, or pediatrician may serve as a Primary Care Physician. Back to top Q. Is my Primary Care Physician given any incentive NOT to send me to a specialist or NOT to provide me with appropriate care? A. No. Your doctor is given incentives to provide you with appropriate care. Hometown Health Plan reviews the care that your Primary Care Physician provides on a regular basis to monitor the frequency that he or she refers care and to be sure you are receiving appropriate care. Note: If your Primary Care Physician is affiliated with the Independent Practice Association (IPA) and uses the IPA specialty providers, please go to "IPA Network Q&A" section. Back to top Q. Do I need a referral for specialty care? A. Yes. You need a referral from your Primary Care Physician before receiving any specialty care. If your Primary Care Physician determines that you need medical care or services from a specialty care provider, he or she will request a referral from Hometown Health Plan to a participating plan provider. This referral will indicate how many visits, the time period, and location. Contact Hometown Health Plan if you have not received your written referral in a timely manner. Exception: Most OB/GYN care does not require a Primary Care Physician referral. Back to top Q. What is the role of a specialty care physician? A. A specialty care physician provides certain specialty medical care upon referral from your Primary Care Physician and authorization by Hometown Health Plan. Back to top Q. Does Hometown Health Plan cover physicals? A. Hometown Health Plan covers routine yearly health assessments, including tests normally made with the examinations. Hometown Health Plan does not provide coverage, however, for a physical for work, sports participation, insurance, school attendance, or any kind of licensure. Back to top Q. I'd like to see a chiropractor or seek alternative medicine. Does Hometown Health Plan cover that? A. Your Primary Care Physician will request a referral from Hometown Health Plan, and you must receive a written referral from Hometown Health Plan prior to using any specialty services. Your office copayment applies. Back to top Q. Whom do I call with an out-of-area emergency? A. You should contact your Primary Care Physician if this ever happens. You may also call Hometown Health Plan, and we will notify your Primary Care Physician. Back to top Refer to your EVIDENCE OF COVERAGE booklet for a detailed description of benefits.

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