Harvard Pilgrim and the Group Insurance Commission (GIC) are updating our product offerings for the 2015–2016 plan year, which takes effect on July 1, 2015. We are replacing our PPO product with the Independence Plan POS product, and will continue to offer the Primary Choice HMO.
The move to a POS plan supports our joint efforts to foster Centered Care and develop affiliations with Integrated Risk-Bearing Organizations (IRBOs). Centered Care is a collaboration among the GIC, Harvard Pilgrim, and provider organizations that emphasizes the principles of the patient-centered medical home, including improving care coordination and access to care, empowering patients to better manage their health, and using performance data to improve clinical outcomes. (For more on Centered Care, see previous Network Matters articles including those in our January and March 2014 issues.)
POS product emphasizes the role of the PCP
The move from a PPO product to a POS product brings with it a key change: all members of the POS product are required to identify a PCP. Similar to the previous PPO product, members who select the Independence Plan POS have a choice between in-network and out-of-network medical services. Harvard Pilgrim and the GIC are conducting outreach (through health fairs, mailings, etc.) to GIC members to educate them about their product options and inform them about the importance of working with a PCP to maintain or improve their health.
Referrals for in-network care
In keeping with Centered Care’s emphasis on coordination of care between PCPs and specialists, referrals will be required for in-network coverage. It’s important that GIC Independence Plan POS members — and the clinicians who treat them — ensure that the member’s PCP makes referrals for specialist visits.
In-network coverage and cost sharing applies for services obtained directly from the member’s PCP or from other Harvard Pilgrim participating providers with the appropriate referrals. Out-of-network coverage and cost sharing (i.e. deductible and coinsurance) applies if the member receives care from non-participating providers or from participating providers without a PCP referral. Certain services, such as routine eye exams and gynecological care, may be obtained without a referral.
Referrals can be made electronically using the HPHConnect or NEHEN transaction services or by telephone, fax, or mail. Please visit the Referral, Notification, and Authorization page of our online Provider Manual for referral guidelines, and information on how to initiate the referral process.
More detailed product information
In-network benefits and cost sharing for the Independence Plan are similar to Primary Choice benefits and cost sharing. Both plans feature a deductible and a three tiered copayment structure for services obtained in the provider network. Copayments for specialist visits, inpatient hospital services, surgical day care, and prescription drugs will increase for both products on July 1, along with the per-member and per-family deductible amounts. The member’s ID card includes copayment information. For information regarding specific benefits and/or copayments, use HPHConnect or call the Provider Service Center at 800-708-4414.
For additional product details, please refer to the GIC Primary Choice HMO and GIC Independence Plan POS product pages in Harvard Pilgrim’s online Provider Manual. For provider tiering information, please visit our provider GIC 2015–2016 plan year webpage .