`
`

`

`
`
`

`

`
`
`
`
`’v1eclica CallLink "'”:
`24»hour Nurse lJne Answers
`Your Health Questions
`
`jage5
`
`Our Goal is to Help Our
`Vlernbers Stay Healthy
`Page 6 & 7
`
`-low to Enr oll
`
`
`
`WHAT’S INSIDE
`
`Welcome to Medica
`
`Page 2
`
`=eatur es of Medica Elect "1"
`and Medica Essentials" Plans
`
`jage3
`
`Questions & Answers
`
`3age 4
`
`Choosing a
`3rirnar 3,! Car e Doctor
`3age 5
`
`

`

`WE LCOME TO MEDI CA
`
`At Medica, we serve members and employers by offering a br oad range of health plans with
`
`many soug ht-atter ieatur es, including:
`
`a choice in selecting doctors and other health car e providers,
`
`and a host oi value—added services. Once again, welcome to Medica.
`
`We know you want the ver y best health car e for yourself and your family . At Medica, we'll do our best
`to make sur e you r eceive high—quality car e — and that you have all the iniormation and support you need
`to make wise decisions ior you and your lamin W e know that being a wise health car e consumer includes
`understanding your health plan. W ith that in mind, we've developed this material
`to introduce you to
`Medica Elect": and Medica Essential care system plans.
`
`- exceptional customer service,
`
`- easy access to health car e,
`
`o a quality—first, member first focus,
`
`- innovative pr eventive car e pr ogra ms, and mor e.
`
`
`No wonder our members consistently give us high marks in satisiaction. But we ar e mor e than just an
`organization that oi iers a variety oi health plans.
`
`We pr ovide access to caring and dedicated health car e proiessionals — including the primary car e doctors
`who make sur e you and your iamin ar e up to date on all oi your imrriunizations, mam mogra ms, aller g
`shots and other pr eventive car e check—ups.
`
`Register ed nurses ar e available 24 hours a day via Medica CallLin k"? The nurses can help you decide in the
`middle oi the night whether you should take your ieverish, coughing child to the emer gency room or Lr eat
`your child at home. They can answer many other health-r elated questions and provide r eierrals to doctors,
`clinics and hospitals.
`
`Medica Customer Service r epr esentatives ar e available by phone during r egular business hours. They can
`answer your questions about a claim or coverage, or give you advice on how to get a pr escription r efilled
`when your e out oi town.
`
`Medica'sW eb site also brings you health car e iniormation 24 hours a day . Log on to t-vt-vi-v .medica.corri to
`locate iniormation about medical conditions or tests, sear ch provider directories, r ead thr ough Medica‘s
`drug iormulary [list oi pr eierr ed drugs] or send a message to Customer Service.
`
`Welcome to the family . Medica is a iamin oi non—pr ofit and ior—proiit businesses: Medica Health Plans,
`Medica Health Plans oiW isconsin, Medica Insurance Company (MIC), Medica Sell-Insured (MSIJ, Medica
`Holding Company and Medica Foundation. Medica Elect and Medica Essential are available through
`Medica Health Plans, MIC and MSI in ar eas with established car e systems.
`
`We are pleased to be able to serve you and one million other members with br oad access to quality car e
`
`

`

`FEATURES OF MEDICA EL ECT®
`
`AND MEDICA ESSENTIAL 5‘“
`
`CARE SYSTEM PLANS
`
`With Medica Elect‘i’ and Medica Essential“ plans, you
`
`select a primary car e clinic that is part of a compr ehensiv'e
`
`care system of primary care and specialty car e providers,
`
`hospitals and other health pr ofessionals. Y our primary care
`
`clinic coor dinates all of your health car e services.
`
`programs ior continuous quality impr ovement
`
`Prescription costs ar e cover ed. When you lill orr efill
`a pr escripLion at a Medica network pharmacy ,you
`areresponsible only for Ihe "copay" — the member‘s
`contribution toward the total costol the drug. The
`rest ol the cost is cover ed. Several national drugstor e
`chains ar e network pharmacies, so you can be assured
`ol getting coverage lor pr escripLion r elills even when
`your e away lr om home. For convenience, members
`can choose to use a mail—or der pharmacy program.
`This service is especially uselul
`to members with
`long—term health conditions who need the same
`medicine on an ongoing basis.
`
`FEATURES OF
`ALL MEDI CA ELECTi2 AND MEDICA ESSENTIAL 1"“
`PLANS INCLUDE:
`
`No claim for ms to file, no bills to or ganize. Simply
`show your Medica ID car d at your Medica
`Elect'” or Medica Essential network clinic each
`
`Lime you r eceive care and we‘ll handle the r est.
`
`Preventive check-ups ar e cover ed. At Medicar
`keeping you healthy is our primary goal. W e covera
`wide range ol pr eventive car e services, when car e
`is directed by your primary car e clinic or physician.
`Check your Summary ol Benelits lor a list ol
`these services.
`
`Emer gency medical costs ar e cover ed —no matter
`where you travel. When you receive emergency
`medical services lr om a network ur gent car e center
`or emergency r oomr you‘r e cover ed. Y ou‘r e also
`covered ior emergency car e r eceived ir om non—
`network providers or hospitals anywhere in the
`world. Just carry your Medica ID car d wilh you and
`travel with coniidence.
`
`Great customer ser vice. No matter which plan you
`choose, you‘ll
`lind that whenever you have a
`question — whether it‘s about beneiits, service or
`any other aspect ol your health car e coverage —
`you'll get pr ompt, helplul and courteous answers
`irom Customer Service. We are very proud that our
`customer satislaction rates ar e consistently high.
`
`Our commitment to quality r ecognized. Medica
`has r eceived "excellent" accreditation status lr om Ihe
`
`Nalional Committee lor Quality Assurance (NCO A”),
`the nation’s leading sour ce lor evaluating the quality
`ol managed car e plans. Medica's excellent status is
`the NCQA 's highest rating.
`It means that Medica
`meets strict NCQA standar ds and has exceptional
`
`

`

`QUESTIONS 8: ANSWERS
`
`ABOUT MEDI CA EL ECT® AND
`
`MEDICA ESSENTIA L5M PLANS
`
`Do I have to select a primar ycar e doctor
`or clinic when l enr ol?
`
`YesY ou and any cover ed lamily members do need
`to choose a primary car e clinic. Family members can
`choose dil ler ent clinics, and you may change clinics
`within your care system plan during the course ol
`the year. Customer Service can pr ovide you with the
`requir emean and pr ocedures lor changing clinics il
`you wish to do so.
`
`Dol need a r e‘fer ral‘fr om my primar ycar e clinic or doctor to see a specialist in my network?
`Your primary car e clinic coor dinates all ol your health car e services. In most cases, to r eceive the highest
`level ol coverage, you will need to be r elerr ed by your clinic or doctor to a specialist.
`
`However, there are some exceptions. Y ou have dir ect access to the lollowing within your Medica Elect '3
`or Medica Essential
`network:
`
`- Urgent care centers
`- OBJ’GYN doctors
`
`- Mental health/substance abuse pr oviders
`- Optorrietrists or ophlhalmologists once a year lor a routine, pr eventive eye exam.
`
`additional infor mation on cover ed services and applicable copays.
`
`Do I need to call Medica befor er eceiving ser vices?
`Generally, no. However,
`to assure that you receive
`appropriate car e, a limited number ol services, pr escn'p tion
`medications and medical supplies require that you obtain author —
`ization belore receiving them. For a complete list you may call Medica‘s
`Customer Service.
`
`Can I see non-network pr oviders?
`You ar e covered lor emergency car e pr ovided by non-network doctors or hospitals anywhere in the world.
`Ilyour doctor relers you to a specialist who is not in the Medica Elect'” plan or Medica Essential plan
`network, contact Customer Service prior to seeing the specialist to learn how your car e will be cover ed.
`
`Check the Summar y of Benefits for each Medica Elect“: plan or Medica Essentials“1 plan to get
`
`

`

`CHOOSI NG A PRIMARY CARE DOCTOR
`
`Medica encourages you to develop a long—ten’n r elationship with one doctor
`
`forr outine car e. That doctor will become familiar with your health, family
`
`and treatment history , which is very helpful when pr oviding car e. And you
`
`will likely feel mor e comfortable seeing the same doctor over time,
`
`instead
`
`of having a new doctor at each visit.
`
`
`or1 600-234» 8319
`
`One ol Medica‘s most popular leatur es is our nurse
`line, Medica CallLink "3. This 24—hours—a—day , BoSdays—
`a—year service is stalled by registered nurses who are
`ready to answer your questions on a variety ol medical
`topics and situations.
`Medica CallLink '3 nurses answer thousands ol calls
`
`Here ar e the thr ee most common types
`of primary care doctors:
`
`Family practice doctors. These doctors specialize
`in taking car e ol the general health needs ol people
`olall ages, lr om inlancy thr ough adulthood. They ar e
`trained in six br oad ar eas ol medicine: pediatrics,
`internal medicine, sur ge'y, obstetrics and gynecology ,
`psychiatry and community medicine.
`
`Inter nists. These doctors specialize in Ihe diagnosis
`and tr eatment ol diseases in adults. They do not
`perlorm surgery, deliver babies or tr eat childr en.
`
`Pediatricians. These doctors specialize in taking
`car e ol the general heath needs ol children, lrcm
`bith thr ough about age 15.
`
`In addition, you have dir ect access to obstetrician-
`gynecologists within your car e system. These
`doctors specialize in pr egnancy and childbirth, and
`in the diseases and r outine physical car e related to
`a woman“ s reproductive system.
`
`Some things to consider when choosing
`a primar y care doctor:
`
`The doctor '5 training and experience. You wantto
`be com lortable that your doctor has the kind ol
`training and experience that is right lor you. Ask
`about his or her experience with ar eas olmedicine
`thatmay be ol special concern to you or your lamily.
`
`The doctor ‘5 accessibility . You wantyour doctor to be
`available when needed. Find out the ol lice hours and
`
`how- long it takes to schedule a r outine visit. Ask who
`covers lor the doctor when he or she is out ol town.
`
`The doctor '5 appr oach to pr eventive medicine.
`You want a doctor who emphasizes staying healthy _
`Note whether the doctor asks you about your lood
`choices, exer cise habits, smoking and alcohol
`
`intake, as well as about any health
`risks you may be exposed to on
`the job or at home. Does the
`doctor r ecommend preventive
`care services such as r outine
`
`physicals, imrr'runizations and rr'Iarr'In'Iograrr'Is? Does
`the doctor answer your questions about how you
`can make healthy impr ovements in your lifestyle?
`
`ll you want help in choosing a primary car e doctor,
`call Medica CallLink {Medic a‘s nurse line. A r elerral
`specialist will help you lind the doctor who best
`meets your needs.
`
`
`MEDI CA CallLink “9
`24-hour Nurse Line
`Answers You' Health Questions.
`
`each year lr om Medica membersThey give advice
`on a wide range ol concerns, lr om how to find a
`heal thr elated support gr oup to how to tr eat a minor
`burn or remedy a child's slully nose.
`
`lind that quick, sound
`With Medica CallLink "2, you‘ll
`medical guidance is only a phone call away.
`Medica CallLink g:
`1-800-962-9497
`
`Hearing-impair ed {TTYJ callers:
`952-992-2357
`
`

`

`OUR GOAL IS TO HE LP OUR MEMBERS STAY HEALTHY
`
`At Medica, our goal is helping you stay healthy .T o that end, we offer members a wide
`
`variety of health education information as well as personalized assistance for members with
`
`certain chr onic diseases. W e encourage you to become an informed consumer of health car e
`services and to take full advantage of cover nd preventive car n services.
`
`
`HEALTH EDU CATION INFOR MATION
`
`Pri-Jdr'ct'i Health Handbook. This aw'ar dwinning sell-
`car e health manual helps you take a more active r ole
`in your health. It covers common health topics, such
`as allergies, back pain, ear inlections and rashes,
`and many other health conditions and symptoms.
`Under each topic, you‘ll lind detailed iniormation on
`home tr eatm en ts and pr even tion, as well as in lorm a tion
`about when to call a health car e pr olessional.
`
`and irr'irr'iunizations.
`
`Member publication. Healthy Ami-tides“ . Medica
`members are mailed a quarterly publication called
`Healthy Attitudeft It contains uselul health educa —
`lion inlormation, pr eventive car e r eminders, ben —
`elits iniormation and mor e.
`
`24-hour nurse line. Medica CallLink '”
`
`is a nurse
`
`PREVENTIVE CARE
`
`line service available to members 24 hours a day
`by telephone.
`Heal'thFor ums Online. Go tot-vt-vt-v .medica.com and
`
`click on the link ior Healthorurr'rs to get iniormation
`about minor illnesses and injuries, routine and
`Lrgent health situations, nutrition, litness and med —
`ications. The site provides access to an easy—to—use
`medical encyclopedia and dictionary , pr escription
`drug inlormation, symptom guide, leatur e articles
`and summaries oi medical journal articles.
`
`Medica strongly believes that appr opriate health
`scr eenings and immunizations ar e vital ways lor you
`to maintain your health.
`
`We work with you and your doctor to inlorm you
`about r ecommended timelines and ages lor health
`screenings. Likewise, we encourage you to work
`with your doctor to stay curr ent with screenings
`
`

`

`See your summary of benefits for a more complete explanation ofmedicai necessity
`
`Disease management. Disease management coor —
`dinates and improves services provided to a
`member lor a given disease or condition, such as
`diabetes or asthma,
`throughout the course ol
`treatment. This includes pr oviding members with
`educational resources to help them understand
`and manage their condition. Disease manage—
`ment encourages pr eventive car e and promotes
`improved member satislaction with the health
`care delivery system.
`
`CARE MANAGEMENT SER VICES
`
`the ongoing medical necessityt and appropriate —
`ness olhealth car e services and treatment plans.
`This review is conducted by a licensed medical
`prolessional as the services ar e being perlormed.
`You may appeal a decision that you or your doctor
`disagrees with. See an outline ol the appeals pr ocess
`in materials that accompany this br ochur e or call
`Customer Service lor additional inlormation.
`
`Case management. Nurse case managers pr ovide
`assistance, education and guidance to members and
`their lamilies who are going thr ough major acute,
`complex and long—terrr'i health pr oblems. The nurse
`case manager works closely with members,
`their
`doctors and com munity r esources to coordinate
`the care being pr ovided.
`
`Dischar ge planning. Discharge planning is the
`evaluation ol a member's medical needs in or der
`
`to arrange appr opriate car e alter the member is
`dischar ged lr om an inpatient setting [hospital or
`long-term-car e lacility].Dischar ge planning pr omotes
`continuity and coor dination ol car e.
`
`“Car e rrianagement" is a gr oup ol services Medica
`provides to make sur e you obtain appr opriate car e
`and to assist in coor dinating benelits and services.
`Car e management is an important component ol
`promoting wellness and includes the following:
`
`0 Prior authorization ol certain services,
`medications and medical supplies.
`
`- Utilization management.
`
`0 Case management lor individuals with
`complex and catastr ophic health pr oblems.
`
`0 Disease management lor members with
`diabetes, asthma and other chronic illnesses.
`
`- Discharge planning.
`Prior authorization. F'rior authorization is a r eview
`ol a limited number ol services, medications or
`medical supplies conducted in advance ol pr oviding
`the service or treatment.
`It
`is intended to deter—
`
`mine their medical necessity" — and to make sur e
`that the car erequested is needed and appropriate
`and will be deliver ed in the proper setting lor
`the optimal length ol time. The r eview also ensur es
`that
`the services are covered under your plan
`benelits. You may appeal an authorization decision
`that you or your doctor disagree with. See an
`outline of the appeals process in materials that
`accompany this br ochure or call Customer Service
`lor additional inlormation.
`
`Utilization management. Utilization managerrientis
`a clinical r eview pr ocess used with a small number ol
`complex medical conditions. The pr ocess checks on
`
`* Medical necessity refers to determining whether hea it}: care services are medically appropriate and needed to meet
`basic health needs, consistent with the diagnosis or condition, and that they are provided in a cost—effective manner.
`
`

`

`HOW TO ENROLL
`
`
`Here are the ‘iour simple steps you should take
`to complete your enr ollment.
`
`1. Select the Medica plan that' s best for you.
`
`3.) days oi the marriage, birth, adoption or placement ior adoption.
`
`Iiyou are declining enrollment ior yourseli or your iamin members
`because oi other health insurance coverage, you may, in the iulur e,be
`able to enroll yoursell or your dependents in this plan, provided that
`you request enr ollment within 30 days oi your other coverage ending.
`In addition, ii you have a new dependent as a r esult oi marriage, birth,
`adoption or placement ior adoption, you may be able to enr oll yourseli
`and your dependents, provided that you request enrollment within
`
`2 If you ar e selecting a Medica Elect “3 plan:
`Choose a primar y car e clinic fr om the Medica Elect 9 network for
`each ‘iamily member . Check the Medica Elect'” provider dir ectory
`(available online at t-vt-vt-v .medicaco m ] to see iiyour curr ent primary
`care clinic is listed and to view available options. Call Customer
`Service ii you have any questions.
`
`If you ar e selecting a Medica Essential 9“ plan:
`Choose a primar ycar e clinic ‘ir om the Medica Essential 9" network
`for each family member . Check the Medica Essential provider
`dir ectory (available online at t-vt-vt-v .medica.co m ] to see iiyourcurr ent
`pn'mary care clinic is
`listed and to view available options. Call
`Customer Service ii you have any questions.
`
`.
`
`If you ar e selecting a new doctor or clinic. call to make sur ethe
`doctor or clinic is accepting new patients. Also, r equest a transier
`olyour medical r ecords ir om your previous doctor to your new one.
`(Your pr evious doctor‘s clinic may char ge you a small lee to cover the
`paperwork and time involved in the transier.)
`
`Complete all enr ollment materials. Please be sure to include the
`Social Security number on the enr ollment iorm and date oi birth ior
`yourseli and each oi your lamin merribers desiring coverage. And
`rememberyou need to identily a primary car e clinic ior each enr ollee.
`
`

`

`
`
`

`

`
`
`

`

`MEDIC&
`myMediBaJmm
`
`AECflUNT: [Groupifl 93m:
`CARE T‘r’F‘E: MEum ELECT-sample
`SHE WP E: ME DEAL
`
`PEP W1EI
`
`PEP F‘H ClNEia':
`
`[999] 999-9999
`
`$931933 93139999599 5m
`ELM SUEM #. 94293
`ID: 499999992
`ram-Ha;
`MAFITHHH LEWlS
`
`Film $19.99
`
`Card NJmlzuen'EardDa’e
`9999999999999999 J'99I'99
`
`Sway: D!
`
`519.99
`
`E
`
`

`

`
`
`

`

`
`
`

`

`
`
`
`
`’v1eclica CallLink "'”:
`24»hour Nurse lJne Answers
`Your Health Questions
`
`jage5
`
`Our Goal is to Help Our
`Vlernbers Stay Healthy
`Page 6 & 7
`
`-low to Enr oll
`
`
`
`WHAT’S INSIDE
`
`Welcome to Medica
`
`Page 2
`
`=eatur es of Medica Elect "1"
`and Medica Essentials" Plans
`
`jage3
`
`Questions & Answers
`
`3age 4
`
`Choosing a
`3rirnar 3,! Car e Doctor
`3age 5
`
`

`

`WE LCOME TO MEDI CA
`
`At Medica, we serve members and employers by offering a br oad range of health plans with
`
`many soug ht-atter ieatur es, including:
`
`a choice in selecting doctors and other health car e providers,
`
`and a host oi value—added services. Once again, welcome to Medica.
`
`We know you want the ver y best health car e for yourself and your family . At Medica, we'll do our best
`to make sur e you r eceive high—quality car e — and that you have all the iniormation and support you need
`to make wise decisions ior you and your lamin W e know that being a wise health car e consumer includes
`understanding your health plan. W ith that in mind, we've developed this material
`to introduce you to
`Medica Elect": and Medica Essential care system plans.
`
`- exceptional customer service,
`
`- easy access to health car e,
`
`o a quality—first, member first focus,
`
`- innovative pr eventive car e pr ogra ms, and mor e.
`
`
`No wonder our members consistently give us high marks in satisiaction. But we ar e mor e than just an
`organization that oi iers a variety oi health plans.
`
`We pr ovide access to caring and dedicated health car e proiessionals — including the primary car e doctors
`who make sur e you and your iamin ar e up to date on all oi your imrriunizations, mam mogra ms, aller g
`shots and other pr eventive car e check—ups.
`
`Register ed nurses ar e available 24 hours a day via Medica CallLin k"? The nurses can help you decide in the
`middle oi the night whether you should take your ieverish, coughing child to the emer gency room or Lr eat
`your child at home. They can answer many other health-r elated questions and provide r eierrals to doctors,
`clinics and hospitals.
`
`Medica Customer Service r epr esentatives ar e available by phone during r egular business hours. They can
`answer your questions about a claim or coverage, or give you advice on how to get a pr escription r efilled
`when your e out oi town.
`
`Medica'sW eb site also brings you health car e iniormation 24 hours a day . Log on to t-vt-vi-v .medica.corri to
`locate iniormation about medical conditions or tests, sear ch provider directories, r ead thr ough Medica‘s
`drug iormulary [list oi pr eierr ed drugs] or send a message to Customer Service.
`
`Welcome to the family . Medica is a iamin oi non—pr ofit and ior—proiit businesses: Medica Health Plans,
`Medica Health Plans oiW isconsin, Medica Insurance Company (MIC), Medica Sell-Insured (MSIJ, Medica
`Holding Company and Medica Foundation. Medica Elect and Medica Essential are available through
`Medica Health Plans, MIC and MSI in ar eas with established car e systems.
`
`We are pleased to be able to serve you and one million other members with br oad access to quality car e
`
`

`

`FEATURES OF MEDICA EL ECT®
`
`AND MEDICA ESSENTIAL 5‘“
`
`CARE SYSTEM PLANS
`
`With Medica Elect‘i’ and Medica Essential“ plans, you
`
`select a primary car e clinic that is part of a compr ehensiv'e
`
`care system of primary care and specialty car e providers,
`
`hospitals and other health pr ofessionals. Y our primary care
`
`clinic coor dinates all of your health car e services.
`
`programs ior continuous quality impr ovement
`
`Prescription costs ar e cover ed. When you lill orr efill
`a pr escripLion at a Medica network pharmacy ,you
`areresponsible only for Ihe "copay" — the member‘s
`contribution toward the total costol the drug. The
`rest ol the cost is cover ed. Several national drugstor e
`chains ar e network pharmacies, so you can be assured
`ol getting coverage lor pr escripLion r elills even when
`your e away lr om home. For convenience, members
`can choose to use a mail—or der pharmacy program.
`This service is especially uselul
`to members with
`long—term health conditions who need the same
`medicine on an ongoing basis.
`
`FEATURES OF
`ALL MEDI CA ELECTi2 AND MEDICA ESSENTIAL 1"“
`PLANS INCLUDE:
`
`No claim for ms to file, no bills to or ganize. Simply
`show your Medica ID car d at your Medica
`Elect'” or Medica Essential network clinic each
`
`Lime you r eceive care and we‘ll handle the r est.
`
`Preventive check-ups ar e cover ed. At Medicar
`keeping you healthy is our primary goal. W e covera
`wide range ol pr eventive car e services, when car e
`is directed by your primary car e clinic or physician.
`Check your Summary ol Benelits lor a list ol
`these services.
`
`Emer gency medical costs ar e cover ed —no matter
`where you travel. When you receive emergency
`medical services lr om a network ur gent car e center
`or emergency r oomr you‘r e cover ed. Y ou‘r e also
`covered ior emergency car e r eceived ir om non—
`network providers or hospitals anywhere in the
`world. Just carry your Medica ID car d wilh you and
`travel with coniidence.
`
`Great customer ser vice. No matter which plan you
`choose, you‘ll
`lind that whenever you have a
`question — whether it‘s about beneiits, service or
`any other aspect ol your health car e coverage —
`you'll get pr ompt, helplul and courteous answers
`irom Customer Service. We are very proud that our
`customer satislaction rates ar e consistently high.
`
`Our commitment to quality r ecognized. Medica
`has r eceived "excellent" accreditation status lr om Ihe
`
`Nalional Committee lor Quality Assurance (NCO A”),
`the nation’s leading sour ce lor evaluating the quality
`ol managed car e plans. Medica's excellent status is
`the NCQA 's highest rating.
`It means that Medica
`meets strict NCQA standar ds and has exceptional
`
`

`

`QUESTIONS 8: ANSWERS
`
`ABOUT MEDI CA EL ECT® AND
`
`MEDICA ESSENTIA L5M PLANS
`
`Do I have to select a primar ycar e doctor
`or clinic when l enr ol?
`
`YesY ou and any cover ed lamily members do need
`to choose a primary car e clinic. Family members can
`choose dil ler ent clinics, and you may change clinics
`within your care system plan during the course ol
`the year. Customer Service can pr ovide you with the
`requir emean and pr ocedures lor changing clinics il
`you wish to do so.
`
`Dol need a r e‘fer ral‘fr om my primar ycar e clinic or doctor to see a specialist in my network?
`Your primary car e clinic coor dinates all ol your health car e services. In most cases, to r eceive the highest
`level ol coverage, you will need to be r elerr ed by your clinic or doctor to a specialist.
`
`However, there are some exceptions. Y ou have dir ect access to the lollowing within your Medica Elect '3
`or Medica Essential
`network:
`
`- Urgent care centers
`- OBJ’GYN doctors
`
`- Mental health/substance abuse pr oviders
`- Optorrietrists or ophlhalmologists once a year lor a routine, pr eventive eye exam.
`
`additional infor mation on cover ed services and applicable copays.
`
`Do I need to call Medica befor er eceiving ser vices?
`Generally, no. However,
`to assure that you receive
`appropriate car e, a limited number ol services, pr escn'p tion
`medications and medical supplies require that you obtain author —
`ization belore receiving them. For a complete list you may call Medica‘s
`Customer Service.
`
`Can I see non-network pr oviders?
`You ar e covered lor emergency car e pr ovided by non-network doctors or hospitals anywhere in the world.
`Ilyour doctor relers you to a specialist who is not in the Medica Elect'” plan or Medica Essential plan
`network, contact Customer Service prior to seeing the specialist to learn how your car e will be cover ed.
`
`Check the Summar y of Benefits for each Medica Elect“: plan or Medica Essentials“1 plan to get
`
`

`

`CHOOSI NG A PRIMARY CARE DOCTOR
`
`Medica encourages you to develop a long—ten’n r elationship with one doctor
`
`forr outine car e. That doctor will become familiar with your health, family
`
`and treatment history , which is very helpful when pr oviding car e. And you
`
`will likely feel mor e comfortable seeing the same doctor over time,
`
`instead
`
`of having a new doctor at each visit.
`
`
`or1 600-234» 8319
`
`One ol Medica‘s most popular leatur es is our nurse
`line, Medica CallLink "3. This 24—hours—a—day , BoSdays—
`a—year service is stalled by registered nurses who are
`ready to answer your questions on a variety ol medical
`topics and situations.
`Medica CallLink '3 nurses answer thousands ol calls
`
`Here ar e the thr ee most common types
`of primary care doctors:
`
`Family practice doctors. These doctors specialize
`in taking car e ol the general health needs ol people
`olall ages, lr om inlancy thr ough adulthood. They ar e
`trained in six br oad ar eas ol medicine: pediatrics,
`internal medicine, sur ge'y, obstetrics and gynecology ,
`psychiatry and community medicine.
`
`Inter nists. These doctors specialize in Ihe diagnosis
`and tr eatment ol diseases in adults. They do not
`perlorm surgery, deliver babies or tr eat childr en.
`
`Pediatricians. These doctors specialize in taking
`car e ol the general heath needs ol children, lrcm
`bith thr ough about age 15.
`
`In addition, you have dir ect access to obstetrician-
`gynecologists within your car e system. These
`doctors specialize in pr egnancy and childbirth, and
`in the diseases and r outine physical car e related to
`a woman“ s reproductive system.
`
`Some things to consider when choosing
`a primar y care doctor:
`
`The doctor '5 training and experience. You wantto
`be com lortable that your doctor has the kind ol
`training and experience that is right lor you. Ask
`about his or her experience with ar eas olmedicine
`thatmay be ol special concern to you or your lamily.
`
`The doctor ‘5 accessibility . You wantyour doctor to be
`available when needed. Find out the ol lice hours and
`
`how- long it takes to schedule a r outine visit. Ask who
`covers lor the doctor when he or she is out ol town.
`
`The doctor '5 appr oach to pr eventive medicine.
`You want a doctor who emphasizes staying healthy _
`Note whether the doctor asks you about your lood
`choices, exer cise habits, smoking and alcohol
`
`intake, as well as about any health
`risks you may be exposed to on
`the job or at home. Does the
`doctor r ecommend preventive
`care services such as r outine
`
`physicals, imrr'runizations and rr'Iarr'In'Iograrr'Is? Does
`the doctor answer your questions about how you
`can make healthy impr ovements in your lifestyle?
`
`ll you want help in choosing a primary car e doctor,
`call Medica CallLink {Medic a‘s nurse line. A r elerral
`specialist will help you lind the doctor who best
`meets your needs.
`
`
`MEDI CA CallLink “9
`24-hour Nurse Line
`Answers You' Health Questions.
`
`each year lr om Medica membersThey give advice
`on a wide range ol concerns, lr om how to find a
`heal thr elated support gr oup to how to tr eat a minor
`burn or remedy a child's slully nose.
`
`lind that quick, sound
`With Medica CallLink "2, you‘ll
`medical guidance is only a phone call away.
`Medica CallLink g:
`1-800-962-9497
`
`Hearing-impair ed {TTYJ callers:
`952-992-2357
`
`

`

`OUR GOAL IS TO HE LP OUR MEMBERS STAY HEALTHY
`
`At Medica, our goal is helping you stay healthy .T o that end, we offer members a wide
`
`variety of health education information as well as personalized assistance for members with
`
`certain chr onic diseases. W e encourage you to become an informed consumer of health car e
`services and to take full advantage of cover nd preventive car n services.
`
`
`HEALTH EDU CATION INFOR MATION
`
`Pri-Jdr'ct'i Health Handbook. This aw'ar dwinning sell-
`car e health manual helps you take a more active r ole
`in your health. It covers common health topics, such
`as allergies, back pain, ear inlections and rashes,
`and many other health conditions and symptoms.
`Under each topic, you‘ll lind detailed iniormation on
`home tr eatm en ts and pr even tion, as well as in lorm a tion
`about when to call a health car e pr olessional.
`
`and irr'irr'iunizations.
`
`Member publication. Healthy Ami-tides“ . Medica
`members are mailed a quarterly publication called
`Healthy Attitudeft It contains uselul health educa —
`lion inlormation, pr eventive car e r eminders, ben —
`elits iniormation and mor e.
`
`24-hour nurse line. Medica CallLink '”
`
`is a nurse
`
`PREVENTIVE CARE
`
`line service available to members 24 hours a day
`by telephone.
`Heal'thFor ums Online. Go tot-vt-vt-v .medica.com and
`
`click on the link ior Healthorurr'rs to get iniormation
`about minor illnesses and injuries, routine and
`Lrgent health situations, nutrition, litness and med —
`ications. The site provides access to an easy—to—use
`medical encyclopedia and dictionary , pr escription
`drug inlormation, symptom guide, leatur e articles
`and summaries oi medical journal articles.
`
`Medica strongly believes that appr opriate health
`scr eenings and immunizations ar e vital ways lor you
`to maintain your health.
`
`We work with you and your doctor to inlorm you
`about r ecommended timelines and ages lor health
`screenings. Likewise, we encourage you to work
`with your doctor to stay curr ent with screenings
`
`

`

`See your summary of benefits for a more complete explanation ofmedicai necessity
`
`Disease management. Disease management coor —
`dinates and improves services provided to a
`member lor a given disease or condition, such as
`diabetes or asthma,
`throughout the course ol
`treatment. This includes pr oviding members with
`educational resources to help them understand
`and manage their condition. Disease manage—
`ment encourages pr eventive car e and promotes
`improved member satislaction with the health
`care delivery system.
`
`CARE MANAGEMENT SER VICES
`
`the ongoing medical necessityt and appropriate —
`ness olhealth car e services and treatment plans.
`This review is conducted by a licensed medical
`prolessional as the services ar e being perlormed.
`You may appeal a decision that you or your doctor
`disagrees with. See an outline ol the appeals pr ocess
`in materials that accompany this br ochur e or call
`Customer Service lor additional inlormation.
`
`Case management. Nurse case managers pr ovide
`assistance, education and guidance to members and
`their lamilies who are going thr ough major acute,
`complex and long—terrr'i health pr oblems. The nurse
`case manager works closely with members,
`their
`doctors and com munity r esources to coordinate
`the care being pr ovided.
`
`Dischar ge planning. Dischar