2023 Member Handbook Retention.08

Member Services

(877) 933-8480 (TTY 711)

Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 OSFMedAdvantage.org

OSF MedAdvantage is administered by Health Alliance™ Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network.

Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Thanks for being a member.

OSF MedAdvantage provides great coverage for your entire well-being and works closely with your health care team through a special collaboration between OSF HealthCare and Health Alliance™. These plans connect the care you trust from OSF with the insurance expertise of Health Alliance.

OSF MedAdvantage plans are custom-built to help keep you healthy, not just treat you when you’re sick. And now, OSF offers more options than ever before to stay in touch with your care team, whether you visit an office or use tools for care at home. OSF MedAdvantage is one more way we’re finding new options for excellent care with excellent coverage.

We can help you with the following and more:

• General membership questions.

• Coverage concerns.

• Questions about doctors, specialists and facilities.

• ID cards.

• Address changes.

• Questions about our extra perks.

• Grievance process.

• Authorization of care.

• Premium payment. Member Services

(877) 933-8480 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30. OSFMedAdvantage.org

Walk-in hours: Weekdays 8:30 a.m. to 4:30 p.m. 3301 Fields South Dr. Suite #105 Champaign, IL

We’ll also walk you through information about our website, ID cards, connecting to your care, pharmacy coverage, extra perks and special programs.

As always, if you have questions, give us a call at the Member Services number on this page. You can also stop by our office. We love to see members in person.

We’re so happy you’re here and want to make sure you know the ins and outs of your plan. Read through this book for key plan information to help you get the most of your coverage.

You can refer to the Key Benefits Guide for information on premiums and copayment or coinsurance amounts for commonly used benefits.

Coverage Checklist

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Get familiar with your plan ID card.

Know your health benefits and make sure you have the plan that’s right for you. We have three different plan options.

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Know your pharmacy benefits and all the ways you can save big on your medication. View our full formulary and pharmacy directory at OSFMedAdvantage.org.

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Know and take advantage of all the perks and programs we offer. Learn more at OSFMedAdvantage.org.

Log on.

Find what you need at hally.com. Get instant access to your coverage in one easy place.

• Go green with paperless member materials online.

• Print ID cards.

• Find doctors, hospitals and pharmacies covered by your plan.

• View past and current claims, authorizations and explanations of benefits.

• Pay your premiums.

• Get access to health, wellness and prevention programs, exercise classes and more.

Online Bill Pay

You can use our easy online payment system at hally.com.

• Make one-time payments.

• Set up recurring, automatic payments.

• View copies of your monthly bills.

• Look at past payments.

And you can choose how you pay. Our system takes payments by:

• Visa, Mastercard and Discover credit or debit card.

• E-check by using your bank account’s routing and account numbers.

Learn about your plan options.

You choose a personal doctor, called a primary care provider (PCP) to manage your care. With a point of service (HMO-POS) plan, which we’ll refer to as POS, you have an in-network PCP to oversee your care and refer you to specialists, but you have the flexibility to see out-of-network providers.

With a health maintenance organization (HMO) plan, you must go to the doctors and hospitals in our large network of trusted providers, unless it’s an emergency or for urgent care.

View your plan’s Evidence of Coverage (EOC) for more information on plan benefits.

OSF Core (HMO)

OSF MedAdvantage Core is a $0 monthly premium plan that gives you access to your trusted OSF HealthCare providers, along with plenty of added perks.

• Comfort of having an in-network PCP to oversee all your care.

• Must see doctors in our large provider network but can go out of network for emergency and urgent care.

• Focus on strong doctor-patient relationships and familiarity with your provider network.

OSF Open (HMO-POS)

OSF MedAdvantage Open gives you the freedom and flexibility to see any doctor who accepts Medicare, along with plenty of added perks.

• Comfort of having an in-network PCP to oversee all your care.

• Flexibility to see out-of-network providers but may save money by staying in network.

• Balance between security and freedom.

OSF Enrich (HMO-POS)

OSF MedAdvantage Enrich lets you see any doctor who accepts Medicare, and you have no out-of-pocket costs when seeking medical care.

• Comfort of having an in-network PCP to oversee all your care.

• Flexibility to see in- or out-of-network providers without any out-of-pocket costs when you go to the doctor or get medical care.

Please refer to the Annual Notice of Change (ANOC) for more details.

We connect you to care.

Health plans, doctors and patients should be on the same team, and with us, they are. We give you access to a large network of trusted doctors, specialists and hospitals close to home.

Primary Care Provider

With your plan, you choose a PCP to serve as your personal doctor who oversees your care and serves as an expert on your health. This doctor works closely with the plan and with you to help keep everyone on the same page with your care and to help make sure you’re getting the care you need.

If you don’t already have a PCP, we can help you select one or choose one for you. You can change your PCP at any time. You may be able to see a physician assistant (PA) or advanced practice registered nurse (APRN) in your PCP’s office. A PA or APRN may be able to see you more quickly, but you can always request to see a medical doctor if you choose.

Use our Find a Doctor search at OSFMedAdvantage.org to find a provider near you, or refer to our provider directory. Our website has our most up-to-date listing of contracted providers.

Prior Authorization

We require members to get approval in advance for some in-network services, like inpatient surgery. When your doctor requests approval from the health plan for certain services, drugs, procedures and treatments, it’s called prior authorization. For services or drugs that require prior authorization, you or your doctor must request it, and it be approved, before the service or drug is given in order for it to be covered. This helps make sure you’re getting the appropriate care for your situation. If you don’t get this approval, your services or prescriptions might not be covered by the plan.

Note: You don’t need prior authorization for a woman’s principal health care provider, also called an OB-GYN, or for your annual eye exam if it’s with an in-network provider. You also don’t need prior authorization in emergencies.

Prior Authorization Process

Your doctor submits authorizations in advance of treatment to our Medical Management department for medical review. The review and approval process can take anywhere from 24 hours to 14 business days, depending on the type of request and medical urgency.

Prescription reviews generally don’t take longer than 72 hours and can be as fast as 24 hours. Medical reviews (if considered medically urgent) can take as little as 72 hours, but if they’re processed as a standard request, they can take up to 14 business days. They usually take less time, but some cases may require additional clinical documentation, which delays the process. In these cases, we’ll ask the doctor for that information.

Once a determination is made, we send a letter to both the ordering doctor as well as the member. If the request is denied, members have the right to appeal the decision in writing within 60 days of the final decision.

Referrals

When your doctor directs you to another provider, it’s called a referral. We don’t require you to get a referral, but your doctor might. Check with your doctor before you see a specialist or other provider to make sure you’ve taken the proper steps.

You might get calls or surveys.

You might receive calls or surveys from us or our partners from time to time. If you’re on at least eight prescription meds and have more than one chronic condition, you may qualify for our medication therapy management program through OptumRx. If you qualify, you’ll get a call from an OptumRx pharmacist who will review your meds with you. Please answer or return the OptumRx call to make sure you’re on top of your prescriptions. O ur care coordinators and health coaches might also reach out occasionally, based on your health situation. If you’re ever in doubt about a call or material you receive, call the Member Services number on the back of your ID card.

Skilled Care

We cover extended care that you need for medical purposes. This type of care can only be provided by or under the supervision of a licensed medical professional, and it usually takes place in a skilled nursing facility but can also be received at home. Some examples are wound care, catheter care, intravenous injections and physical therapy. Care that’s not for medical purposes, either at home or in a nursing home or assisted living facility, is not considered skilled care. It’s called custodial care.

It can be safely provided by a non-licensed caregiver, and therefore, it’s not covered by your plan or Original Medicare if it’s the only care you need. But you can look into other options, like nursing home or long-term care insurance from a third party.

Know where to go.

OSF 24/7 Nurse Line

You can access registered nurses anytime, anywhere with the OSF 24/7 Nurse Line. Our team of trained and highly qualified nurses is available when and where you need us. We can help answer questions about your health, connect you to care or help guide you to the best location to receive the care you need. Call the OSF 24/7 Nurse Line anytime at (877) 673-4951.

Digital Health Options

OSF MedAdvantage plans include options to receive care and navigate your health digitally from the comfort of your home. Also included is the ability to connect 24/7 with OSF OnCall Urgent Care – at no extra cost. Chat, video call or send us your questions about a minor illness or injury – anytime, day or night. And then there’s Clare, our chatbot at osfhealthcare.org. Clare can help you find a clinic near you, schedule a vaccination, help make an appointment, direct you to the care you need based on symptoms you may be having and much more.

Access all of these digital care options from osfhealthcare.org/member.

Urgent Care

(Convenient Care or a Walk-In Clinic)

If you can’t get an appointment with your PCP or you’re traveling, go to urgent care if your injury or illness is not an emergency. This can help you save time and money compared to the emergency department. You may need to pay upfront at some urgent care facilities but will be reimbursed. Pay attention to your bills to make sure you’re billed for urgent care. If it’s billed as a traditional office visit and is out of network, coverage may be denied on an HMO plan.

Emergency Care

Some injuries or illnesses require trips to the emergency department. If your injury or illness doesn’t require immediate medical attention, calling your doctor or going to an urgent care clinic (sometimes called convenient care or a walk-in clinic) can save you time and money. Going to the emergency department for non-emergencies can drive up costs for you and health services overall, and the emergency department doesn’t know your full medical history like your doctor does. Plus, it usually has long wait times.

But in the following situations, always go to the emergency department or call 911.

• Stroke symptoms.

• Chest pain.

• Head or spinal injury.

• Severely broken bone.

These are examples, not a complete list. If you think your condition is a life-threatening emergency, call 911 or go to the nearest emergency department. Then, after you’ve received treatment, contact your PCP and us. This will help us coordinate your care after your visit.

Your plan covers emergency and urgent care out of network, so even if you’re traveling, you can still get the care you need without having to worry about finding an in-network facility.

Telehealth Coverage

If you need to interact with your PCP or specialist over the phone or online, you’re covered through the telehealth benefit. If you see an OSF provider, many outpatient appointments can be completed through OSF MyChart. While some medical care requires in-person appointments, many visits can be effective and convenient through secure phone or video chat. Copayment may apply.

Pharmacy Programs

You can go to any network pharmacy to save on prescription drugs.

Rx Deductible

Our OSF MedAdvantage Core and OSFMedAdvantage Open plans don’t have a pharmacy deductible, but for the OSF MedAdvantage Enrich plan, you must meet a $175 yearly deductible on Tiers 3 – 5. After that, you pay the copays listed in the Stages of Pharmacy Coverage chart.

90-Day Supply Options

With our mail-order benefit, you can get a 90-day supply of your drugs delivered directly to you for two copays. If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply for three copays.

Medication Home Delivery

We’ve partnered with OptumRx to offer home delivery anywhere in the U.S.

• Pay less for your medication with a three-month supply.

• Get free standard shipping on medications delivered straight to your door.

• Request a free Deterra® bag to dispose of unwanted medication and help prevent misuse.

To sign up, visit OptumRx.com, use the OptumRx app or call the number on the back of your member ID card.

Medication Therapy Management

If you’re on at least eight prescription meds and have more than one chronic condition, you may qualify for our medication therapy management program through OptumRx. This program helps you:

• Take your medications as your doctor prescribes.

• Solve problems that come up with your medications.

• Make sure taking different medications at the same time is safe.

If you qualify, you’ll get a call from an OptumRx pharmacist who will review your meds with you. Please answer or return the OptumRx call to make sure you’re on top of your prescriptions.

Transferring Prescriptions

Made Easy

You can transfer your prescriptions to a different in-network pharmacy. Many pharmacies let you transfer prescriptions over the phone, online or in person. Just make sure the new pharmacy is still in network.

Remember, when transferring prescriptions, don’t wait until the last minute.

Drug Disposal Boxes

OSF HealthCare helps reduce the misuse of medications by offering safe, secure disposal boxes for the public at each hospital across our ministry. The containers can be locked and are always monitored when open, similar to a mailbox. You can drop off any drug (prescription or over-the-counter), except needles or other sharp objects, liquids, inhalers, aerosol cans, IV bags or tubes, and thermometers.

Members also have access to Deterra®, a safe and convenient way to get rid of unwanted medication. You must call OptumRx at (800) 562-6223 and register a home delivery account (but you don’t have to agree to home delivery). Tell the OptumRx customer service rep you need a kit to dispose of unneeded meds. The kit should arrive in 7 – 10 business days.

Stages of Pharmacy Coverage

INITIAL COVERAGE

Initial Coverage

(Most people stay in this stage.) You pay the following amounts until the amount you pay plus the amount we pay reaches $4,660.

Coverage Gap

Also known as the “donut hole,” this stage begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,660. Here, you pay the following until you reach $7,400:

• 25% for covered generic drugs.

• 25% for covered brand-name drugs.

Coverage Through the Gap

If your total prescription spend adds up to $4,660, you’ll reach the coverage gap. With your OSF MedAdvantage plan, you’ll continue to pay your copay for Tier 1 medications until your out-ofpocket expenses reach $7,400.

Most people stay in this stage. Few people reach this stage. Even fewer people reach this stage.

*OSF Enrich coinsurance is 30% for Tier 5.

Catastrophic Coverage

(Even fewer people reach this stage.) This stage begins when your out-of-pocket drug costs reach $7,400. Here, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following:

• 5% of the cost.

or

• $4.15 for covered generic drugs (including brandname drugs treated as generic) and $10.35 for covered brand-name drugs. Retail Rx Costs By Tier

Make your meds a priority.

Tips to Remember

• Take meds at the same time each day. Use a daily event, like brushing your teeth, to help you remember.

• Use a pill box with separate sections for each dose.

• Use a medicine calendar or set a reminder on your smartphone.

• Ask family or friends to help remind you to take your meds.

Help at Your Pharmacy

• Ask about automatic refills so you don’t fall behind.

• See if the pharmacy can call, email or text you when it’s time for a refill.

• Ask your pharmacist any questions you have about your meds or how to take them.

• Ask your pharmacist if there’s a drug option that costs less.

Good Things to Know

• If you take more than one medicine, ask about interactions and when to take each medication.

• Don’t skip doses. Medicine only works when you take it regularly.

• Never stop taking prescription medicine on your own, even if you start feeling better.

• Call your doctor right away if you have any negative side effects from your meds.

It’s important to take your meds as prescribed to keep your health issues in check.

Care coordinators and health coaches help you meet your health goals.

Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we’ve got you covered. We give you programs to help you achieve your goals or get you back on track.

Find helpful resources.

Care for yourself to help prevent illness and hospital stays.

A Team Focused on You

Set and reach health and wellness goals.

Understand and manage health issues, like diabetes and asthma.

Use your health benefits to save money.

Coordinate your care when you have complicated health conditions.

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Care Coordination

We connect you to a team that works with your doctors and takes your personalized plan a step further, giving you extra help and resources along the way.

Connect to a team of providers, like nurse practitioners, social workers, health coaches, dietitians, pharmacists and more, who work with your doctor to make sure you have the resources you need to stay healthy or work through your medical issues.

The care coordination team reaches out to offer these services, but you can also request them if you’d like this personalized help.

Perks and Programs

We’re not only here to help when you get sick or hurt. We’re here to help you stay healthy in the first place, so we offer plenty of perks and programs to help you get the most from your coverage. Go to OSFMedAdvantage.org to learn more.

Be Fit

Get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. Scan the QR code with your phone’s camera for the Be Fit Reimbursement Form.

Activities include the following and more:

• Fitness class fees.

• Gym memberships.

• Online fitness subscriptions.

• Weight loss subscriptions.

• Ski memberships.

• Rowing.

• Golf.

• Bowling.

• Tennis.

• Pickleball.

• Recreational league fees.

• Pool exercise classes.

• 5K/10K race fees.

If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers or personal equipment.

Companion Benefit*

Get up to 30 hours of in-home support yearly through the Papa Pal program. This service gives you access to a friendly companion who can help you with a variety of tasks. Plus, they can be a fun person to chat with. And they can go with you to places like a library, park, doctor’s office, pharmacy and more.

Services include:

• Companionship (like playing games, eating lunch or having a conversation).

• Transportation.

• Technical support (like setting up streaming platforms or teaching you how to make a video call).

• Light help around the house.

• Light exercise.

• Grocery shopping.

• Help with your pet.

Services are typically provided in one-hour increments.

Dental Coverage

We cover up to $2,000 a year for use on dental services, like cleanings, X-rays and more. You pay the dentist and then send us the receipt. If your dentist submits the claim for you, you don’t need to send us the receipt. There’s no set network, so you can go to any dentist you choose. (OSF MedAdvantage Enrich has a $1,750 coverage limit.)

You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.

Disease Management Programs

Get connected to resources, motivation, support and reminders to help you manage the following and more:

• Asthma.

• Diabetes.

• High blood pressure.

• Congestive heart failure.

• Migraines.

OSF OnCall Urgent Care

Included in your OSF MedAdvantage benefits is the ability to connect 24/7 with OSF OnCall Urgent Care –at no extra cost. Chat, video call or send us your questions about a minor illness or injury – anytime, day or night. Get started at osfoncall.org/virtualcare.

Get seen for these conditions:

• Allergies.

• Cold/flu.

• Ear problems.

• Fever.

• Minor allergic reactions.

• Skin conditions.

OTC4Me

• Sore throats.

• Sprains and strains.

• Urinary tract infections.

• Upper respiratory infections. And many more.

Vision Coverage*

Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider. Plus, get a $150 allowance for eyewear.

Wellness Rewards*

Take steps toward better health while working your way toward a $50 gift card through our claims-based Wellness Rewards Program. Become eligible for your reward by completing certain wellness activities. There’s no need to submit any paperwork. Learn more at OSFMedAdvantage.org

whiskerDocs

Get a 10% discount code for a wide variety of competitively priced over-the-counter (OTC) products with OTC4Me. You can order online or by phone, and all orders are shipped directly to you. Shipping is free on orders over $25.

Preventive Care

Here are just some of the many services we cover:

• Yearly wellness visit.

• Routine screenings (like mammograms or colorectal cancer screenings).

• Flu shot.

Quit For Life®*

Get help ending your tobacco use with:

• One-on-one coaching from a quit coach.

• Quit plan made just for you.

• Helpful tools, like Text2Quit®.

• Web Coach®, an online learning and support community.

Connect to 24/7 help from veterinary technicians with whiskerDocs. You can call, chat or email with questions about your animals’ health or well-being. The service helps with cats, dogs, birds, reptiles and pocket pets (like rabbits or hamsters). About 60% of issues are taken care of over the phone without a visit to the veterinarian.

*Not available on Enrich plan.

Assist America® and Other Benefits to Use When Traveling

Have peace of mind whenever you travel 100 miles or more from home. With doctors, nurses and emergency medical technicians on staff, help is just a phone call away, 24 hours a day and 365 days a year.

Assist America can connect you to prompt medical attention and help make sure you’re admitted to reliable hospitals when needed. Plus, it can even help in some situations that aren’t health-related.

Here are just some of its many features:

• Prescription assistance if you need medication or left your prescription behind.

• Compassionate visit from someone close to you if you need to be hospitalized for more than a week.

• Emergency medical evacuation.

• Lost luggage assistance.

• Interpreter and legal referrals.

All Assist America benefits apply on all of our Medicare Advantage plans, but when you’re out of network, our HMO plan covers only emergency and urgent care.

Assist America will not pay you back for ambulance and other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.

Helpful Travel Reminders

Remember, you also have access to OSF OnCall Urgent Care for questions about minor illness or injury –anytime, day or night, online or by phone. Get started at osfoncall.org/virtualcare.

You can also call the OSF 24/7 Nurse Line at (877) 673-4951 to get advice from a nurse about your current health situation, no matter where you are.

Plus, all members, regardless of plan type, have coverage for out-of-network emergency and urgent care. Members with POS plans have out-of-network coverage built into their plans but may save by staying in network. Check your benefits chart for copay or coinsurance amounts. Call the Member Services number on the back of your ID card if you have questions.

Your Rights and Responsibilities

As our member, you have rights and responsibilities.

Rights

• You have the right to be treated with respect and recognition of your dignity and the right to privacy.

• You have the right to reasonable access to health care.

• You have the right to participate with contracted providers in making decisions about your health care.

• You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

• You have the right to receive information about OSF MedAdvantage, our services, our contracted providers, and your rights and responsibilities.

• You have the right to make complaints or appeals about OSF MedAdvantage or the care provided.

• You have the right to make recommendations regarding the OSF MedAdvantage rights and responsibilities policies.

Responsibilities

• It’s your responsibility to read and understand your Evidence of Coverage and any attached riders or amendments and to follow the rules of membership.

• It’s your responsibility to know what providers are in your network.

• It’s your responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.

• It’s your responsibility to follow the plans and instructions for care you have agreed on with your providers.

• It’s your responsibility to provide (to the extent possible) information OSF MedAdvantage and our contracted providers need in order to provide care.

• It’s your responsibility to notify OSF MedAdvantage in a timely manner of any changes in your status as a member, such as name, address or marital status.

Changing Your Plan and Disenrollment

Changing Plans

The Annual Enrollment Period (AEP) is the time each year, determined by the Centers for Medicare & Medicaid Services (CMS), when you can enroll in a plan or switch to a new one. Typically, this is the only time each year you can make changes, unless you meet special exceptions. If you’re happy with your plan, no need to do anything. Your policy will renew automatically on January 1.

The AEP is October 15 through December 7 each year with plan coverage starting January 1. Please contact our Member Services Department if you have questions. We may have a different plan available in your area that could be a better fit for your current situation. If you would like more information on your options, call Member Services at the number on the back of your ID card.

Disenrollment

If you decide to disenroll, this means you’re ending your membership. Disenrollment can be voluntary (your choice) or involuntary (not your choice).

If you decide you want to leave your plan, you can do this for any reason. However, there are limits to when you may leave, how often you can make changes and what type of plan you can join after you leave.

Call Member Services at the number on the back of your ID card for more information.

Reasons OSF MedAdvantage May Disenroll You

• You move permanently out of the plan’s service area and do not voluntarily disenroll, or you live outside the plan’s service area for more than six months a year.

• Your entitlement to Medicare Part A or Medicare Part B ends.

• You supply fraudulent information or make any misrepresentations on your enrollment request form that materially affect your eligibility to enroll in the plan.

• Your behavior is disruptive, unruly, abusive or uncooperative to the extent that your membership seriously impairs our ability to arrange covered services for you or other individuals enrolled in the plan.

• You knowingly permit abuse or misuse of your OSF MedAdvantage ID card.

• You fail to pay plan premiums, copayments, coinsurance or other payments required by the plan.

• The contract between OSF MedAdvantage and CMS, which certifies Medicare plans, is terminated.

10 Frequently Asked Questions

For OSF MedAdvantage Members

1. How and when should I reach out to Member Services?

• You can reach Member Services by calling the Member Services number on the back of your ID card. You should have your member number ready. You’ll be prompted to make selections based on your type of question.

• Call Member Services for answers to questions about your plan, including topics like eligibility, premiums, claims, prescriptions, authorizations, letters and more.

2. Should I expect to receive a monthly premium statement for my plan?

You should expect to receive a monthly statement:

• For the first bill of the plan year regardless of how you pay.

• If you make premium payments by mail or phone or make a one-time payment online.

• If your plan has terminated but there is a past-due balance (not turned over to collections).

• If you’ve opted out of online billing and have autopay but wish to receive a paper statement.

You should not expect to receive a monthly statement:

• If you set up recurring payments (using our mail-in Automatic Premium Payment form or by setting up recurring payments online by logging in at hally.com)

• If you set up Social Security withdrawal.

• If your policy was terminated and the account has a $0 balance.

3. What is the difference between copay and coinsurance?

Both copay and coinsurance are your responsibility of the cost for medical services. A copay is a fixed or flat dollar amount you pay for a given service, whereas coinsurance is a percentage you’re responsible for paying. (Example: 20% coinsurance means we pay 80%, and you pay 20%.)

Always call Member Services first for claims issues. We can help you figure out if the claim has been submitted to us properly and if it’s been paid partially or in full, and we can direct you on next steps. There are some reasons you may receive a bill and/or why a claim may not be paid correctly or completely, like claims being submitted to the wrong insurance company, incorrect coding, filing in an untimely manner, a service that’s not covered, processing errors and others.

5. How can I check if a provider or facility is in network?

• Call Member Services at the number on the back of your ID card.

• Use our Find a Doctor search at OSFMedAdvantage.org , or refer to our provider directory.

• Log in at hally.com to check if a provider or facility is in network.

4. What steps can I take to resolve a claims issue (if I’ve been billed for charges by a provider/facility that I thought was covered by my plan)?

6. How can I check if there are any benefit changes to my plan for the new plan year (starting January 1)?

Benefits and other aspects of a plan are likely to change to some degree (annually) even if you keep the same plan. Here are some of the ways you can identify the changes:

• Review your Evidence of Coverage (EOC) and Annual Notice of Change (ANOC).

• Go to OSFMedAdvantage.org to find your Evidence of Coverage (EOC) and Annual Notice of Change (ANOC).

• We’ll also mail you an ANOC for your plan every September.

• Call the Member Services number on the back of your ID card. We can help you with any benefit change questions you might have for your plan.

7. How can I get approval for a prescription that requires prior authorization?

• Ask your doctor’s office to contact our Pharmacy department at (800) 851-3379, option 4, to start the authorization over the phone.

• You or your appointed representative can start the authorization over the phone.

• Your doctor’s office may also submit a prior authorization form by fax to (217) 902-9798.

8. How can I make a premium payment?

• Call the Member Services number on the back of your ID card and choose “Make a Payment” using our automated system.

• Mail a check with your statement stub.

• Submit an Automatic Premium Payment form to us and have the payment taken from your credit card or bank account.

• Pay your premium via Social Security withdrawal.

• Make a one-time premium payment (or set up recurring payments) online by logging in to hally.com .

9. What is the difference between a deductible and an out-of-pocket maximum?

A deductible is a designated amount members pay toward medical or pharmacy expenses before their copay or coinsurance kicks in. The out-of-pocket maximum (OOPM) is the amount you pay for health care expenses in a given plan year before we start to pay 100% of covered expenses. You no longer pay copayments or coinsurance, just your monthly premium. In-network services (also referred to as Tier 1 and Tier 2) both apply to the in-network OOPM. Note that if you receive services that are non-covered or use out-of-network providers (referred to as Tier 3), you may be required to cover costs above the OOPM. There is no cap on the amount that you may have to pay for non-covered services or using out-of-network providers.

10. How do I register online at hally.com, and why should I sign up?

To create an account, go to hally.com. While you’re logged in to hally.com, you can:

• Sign up for text alerts.

• Go paperless by opting in for secure e-Delivery of your plan materials.

• Know where to go for care depending on your symptoms.

• Pay your monthly premium using Premium Bill Pay and set up recurring payments.

• View past and current claims, authorizations and Explanations of Benefits.

• Find doctors, facilities and pharmacies covered by your plan.

• Check your spending.

Helpful Terms

Coinsurance

The percentage you pay for services at a doctor’s office, pharmacy or hospital.

Copayment

The fixed dollar amount you pay for services at a doctor’s visit, pharmacy or hospital.

Coverage period

The stretch of time your plan covers you, usually January 1 to December 31 each year.

Deductible

The amount you pay before your benefits kick in.

Drug tier

The cost group a drug belongs to. Generally, you pay less for lower groups.

Formulary

A list of common medications grouped by drug class (how they work) or by the medical problem they treat. We generally only cover drugs listed in the formulary.

Generic drug

A drug that has the same active ingredients as a brandname drug but costs less.

Health maintenance organization (HMO)

With an HMO plan, you choose a PCP to oversee your care and refer you to specialists. You must stay in network, unless it’s an emergency or for urgent care.

Network

The doctors, clinics and hospitals a health plan works with to provide discounted services to members.

Point of service (POS)

With a POS plan, you choose an in-network PCP to oversee your care and refer you to specialists. You have the flexibility to see out-of-network providers, but you may save money staying in network.

Prior authorization

A review process your doctor asks for to see if your plan will cover certain drugs or services before you get them.

Premium

The monthly fee you pay for coverage.

Preventive care

Helps find and treat medical problems before they become serious or life-threatening. Preventive care includes routine exams, lab tests, screenings and vaccines.

Provider

A doctor, nurse, physician assistant, etc., you see for health care. You choose a PCP as the main provider to oversee your care and refer you to specialists.

Urgent care/Walk-in clinic

If you need care now, but it’s not an emergency and you can’t get into your PCP, you can go to an urgent (or convenient) care clinic.

Yearly Limit

The most you’ll pay in a coverage period before your plan pays 100% of covered expenses. It’s also called the outof-pocket maximum.

Learn more about your health plan:

HealthAlliance.org/HealthPlan