The following information applies to current HMO members in areas no longer served by FirstCare HMO as of September 1, 2009 (Abilene, Amarillo, Lubbock).
If you are currently enrolled in FirstCare, and your area will no longer be served by FirstCare beginning September 1, you should know some important things about transitioning to HealthSelect. You and your currently enrolled dependents will be automatically enrolled in HealthSelect effective September 1, 2009. You will not have to enroll and no proof of good health, called evidence of insurability (EOI) is required. If you wish to add dependents to your health coverage who are not already enrolled in FirstCare, you can do so during Summer Enrollment without EOI as long as you live or work in a county with no HMO available as of September 1, 2009.
In order to receive network benefits, which keeps your out-of-pocket costs low, you need to designate a primary care physician (PCP) in the BlueChoice (HealthSelect) network. Do this as soon as possible for yourself and for each of your enrolled dependents, even if your current PCP with FirstCare is also a provider in the BlueChoice network.
To choose your PCP, you may complete a GBP Supplemental Information Form and mail it to BCBSTX. You can download a GBP Supplemental Information Form from the ERS website or get a form from the HealthSelect website. You can also call BCBSTX Customer Service at (800) 252-8039, log in to Blue Access for Members and send BCBSTX your request through email or Live Chat, or designate your PCP in ERS OnLine through the ERS website: www.ers.state.tx.us
You will be eligible for network benefits during your first 60 days of coverage if you receive care from any network PCP and have not designated a PCP. During this grace period, if you have an office visit with a network PCP you are responsible for the $20 PCP office visit copayment. If you have not chosen a PCP after the initial 60-day grace period, only non-network benefits will be available to you until you contact BCBSTX and select a network PCP.
Once you have selected a PCP, you receive network benefits when seeing that PCP and are responsible for a $20 PCP office visit copayment and any applicable coinsurance. After the 60-day grace period, if you have not designated a network PCP, you will receive non-network benefits, which could mean a significantly higher out-of-pocket cost for you.
You should receive your new HealthSelect medical ID card before 9/1/09. If BCBSTX has not received your PCP selection, your card will state "NO PCP ON FILE."
If you have a referral in place for specialist care, be sure to set up a new referral to a network specialist once you have designated your PCP. The same applies to any pre-authorization you have obtained for inpatient hospitalization.
In certain cases, you may be eligible for transitional benefits, extended to members whose specialist is not in our network and their care falls into one of the six categories listed here:
- Terminal illness, meaning a life expectancy of six months or less
- Prescheduled surgery to be performed on or after 9/1/09
- Acute care following trauma or recent surgery
- Chemotherapy (in current course of treatment)
- Psychiatric treatment (transitional referral limited to a maximum of 60 days)
- Obstetrical care, if you are in the third trimester of pregnancy on your HealthSelect effective date or when the physician terminates from the network.
If you are being treated now for any of these conditions, and your provider is not part of the BlueChoice (HealthSelect) network, you may be eligible for transitional benefits. If approved by BCBSTX for transitional benefits, you would be allowed to continue treatment with your current health care provider while your care is switched to a BlueChoice provider.
To apply for transitional benefits, you must complete a transitional benefits form. You can request this form from HealthSelect by calling BCBSTX Customer Service at (800) 252-8039. Or you can get the form from the HealthSelect website. Be sure to complete and submit the form as early as possible so that, if you are approved, your transitional benefits will begin on September 1, 2009. Make sure you apply for transitional benefits before September 1, 2009.
BCBSTX will review your application and notify you of our approval or denial for transitional benefits.
If the PCP and specialist you were seeing in FirstCare are both in the BlueChoice network, then all the PCP needs to do is request a referral under the HealthSelect plan to continue care.
