Benefit Limitations

WHAT IF MY BENEFITS RUN OUT?

WE HOPE THAT AS AN AMERICA’S 1ST CHOICE MEMBER, YOU HAVE ENJOYED THE ACCESS TO CARE AND ALL THE BENEFITS WE ARE PROUD TO OFFER YOU. AS WITH ANY HEALTH PLAN, THERE ARE CERTAIN BENEFITS THAT CAN RUN OUT.

Some benefits such as physical therapy, prescription coverage and nursing home care have a yearly limit but they are renewed the following year. It helps to know which benefits can run out ahead of time so that you can better prepare. The Health Plan can help you explore your options.

We urge you to review your Evidence of Coverage information that we mailed you upon enrollment. If you have any questions about your Evidence of Coverage, please call member services toll free at: 1-888-563-3289 or TTY: 711.

Your Evidence of Coverage provides you with detailed information of your benefits, including which benefits may have yearly or benefit period limits. This will allow you to plan ahead. If you know you will run out of a benefit soon or already have, the Health Plan Social Worker may be able to help you find resources.

Here are some examples of members exhausting their benefits or needing help transitioning to other care:

  • IT IS POSSIBLE TO USE UP YOUR INPATIENT DAYS: this may happen when you are admitted to a hospital or skilled nursing facility for a lengthy period of time. Your inpatient benefit days could run out if you reach the number of days threshold and have not stayed out of an inpatient setting for 60 consecutive days; this would reset the benefit period.
  • “DONUT HOLE” OR COVERAGE GAP: this can be a stressful time when your prescriptions cost more. Talk to your doctor about what medications work with your conditions. Be honest and discuss what you can afford. There might be alternatives that will work for you. The good news is that there are programs and resources that can help you during the coverage gap.

The doctor-patient relationship is an important one. It is built on trust and communication. It is necessary to be able to communicate well with your doctors. This is true whether it is your Primary Care Physician (PCP), a Specialist, or if you are in the hospital. When you feel you are able to openly talk to your doctor, you can have better health results. Your doctor wants to help you with your health. Better health results improve your overall well-being.

  • TRANSITION FROM PEDIATRIC TO ADULT CARE: our member services team is able to help members switch over to an adult primary care physician once they reach adulthood.
  • RUNNING OUT OF YOUR SKILLED NURSING BENEFITS: and you don’t feel that you can take care of yourself at home. The Health Plan’s Social Services team may be able to help. They can assist you by connecting you with available community resources and charities in your area.

There are programs that can assist you with some of your care needs to support you in your home. This may include a home meal delivery program or access to other charities in your area. Many people find support programs through their Church or social network.

We want you to focus on achieving your health goals without worrying about benefits running out. Please give us a call if you are concerned about a particular benefit.

Last Updated: 10/12/2018