State of Illinois
Healthcare Coverage Made for You 2022-2023 Member Handbook
When it comes to coverage, it’s all about you. Welcome to a health plan made with you in mind – access to doctors you trust, perks you deserve and customer service reps always ready to help. We’re happy you’re here and are excited to help you use your plan and all its perks made to fit your needs. Thanks for being a member.
Your Steps to Getting Started 1. W e’ll mail your ID card shortly after you enroll. Plus, you can access a digital ID card by logging in to hally.com about 10 days before your plan starts.
2. Make sure your doctor’s office and pharmacy have your new ID card on file. 3. K now where to find your secure member information using hally.com and the Hally® app. Visit the App Store or Google Play to download.
4. If you have questions, call Customer Service at (800) 851-3379 (TTY 711). App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
Your Care and How It Works Your plan is made to give you access to the care you need from a large network of providers you trust. Our statewide network of doctors, hospitals and clinics connects you to world-class care with names you already know and trust. Wherever you’re at in Illinois, we connect you with the care you deserve.
In-Network Care
Prior Authorization
You have access to a group of doctors, hospitals, pharmacies and other providers who agree to give you care at a discounted rate. Log in at hally.com, use the Hally app or call Customer Service to find in-network doctors, hospitals and pharmacies.
For specific drugs or services, your doctor must request prior authorization to make sure you meet certain requirements before we’ll cover them. To find out if a drug or service requires prior authorization, please refer to your policy document.
For a full list, visit: HealthAlliance.org/State-of-Illinois
Providers can submit a prior authorization one of the following two ways:
Out-of-Network Care With your health maintenance organization (HMO) plan, you can go out of network for emergency situations. If you have an urgent or emergency situation, we’ll still cover your claims at the in-network level anywhere you go.
In-Network Specialty Care We don’t require you to get a referral to see an in-network specialist, 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. If there’s no in-network specialist to treat your specific condition, we’ll help you find one. And you’ll still pay the in-network cost if you get prior authorization from us.
• Submit
a prior authorization request through our provider website.
• Fax
a prior authorization form to
(217) 902-9798. Decisions are made within 24 to 72 hours of your provider’s request.
Your Care Options When you get sick or injured, it’s sometimes hard to know where to go for care. Your plan is made with plenty of options for different situations based on how severe your condition is, where you are and other factors.
Nurse Advice Line
Emergency Care
Call (855) 802-4612. Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.
Some injuries or illnesses require emergency care, but 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 increase costs for you and healthcare overall, and the emergency department doesn’t know your full medical history like your doctor does. Plus, it usually has long wait times.
Primary Care Provider (PCP) Try setting up an appointment with your PCP if your injury or illness isn’t an emergency. Your PCP knows your health history and helps oversee your care.
Urgent Care (Convenient Care or 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 isn’t 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 your service is billed as a traditional office visit and is out of network, coverage may be denied on HMO plans.
lways go to the emergency department or A call 911 if you experience: • Stroke symptoms. • Head or spinal injuries. • Chest pains. • Severely broken bones. 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.
Your Pharmacy Coverage Plans with pharmacy coverage built right in help you keep all your coverage in one place and help you save with special programs and discounts made for you.
Prescriptions
Drug Formulary
Where you get your drugs filled matters. Log in at hally.com, use the Hally app or call Customer Service to find an in-network pharmacy near you.
You can find a list of drugs covered by your plan, including the payment tier for each drug, using the formulary. Drug coverage is voted on by the P&T (Pharmacy and Therapeutics) committee. It consists of a group of clinical pharmacists, medical directors and doctors in various specialties.
Before you go, check the drug formulary for your drug’s tier at hally.com or on the Hally app. Every drug listed in our formularies is put into a cost group, or tier. You typically pay the lowest price for a Tier 1 drug. As you step up to the next tier, the amount you pay increases. Your provider can call our Pharmacy department at (800) 851-3379 (option 4) to ask about lower-cost options for your drugs. See the list of drugs we cover in our formulary at HealthAlliance.org/Pharmacy.
Mail-Order Discount You can order a 90-day supply of prescription drugs through the mail for a discounted rate. Learn more about the program by calling OptumRx, your pharmacy benefits manager, at (800) 763-0044.
Your Care Team Your plan is made for more than when you’re sick. It’s made to help you stay healthy in the first place, so you have a team of health coaches, care coordinators and more to help you with both.
Care Coordinators Set and reach health and wellness goals.
Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we have teams to help you achieve your goals or get you back on track. 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 free services, but you can also request them if you’d like this personalized help.
Find helpful resources.
Understand and manage health issues, like diabetes and asthma.
Care for yourself to help prevent illness and hospital stays.
Coordinate your care when you have complicated health conditions. Use your health benefits to save money.
Your Health at Your Fingertips We know with everything going on in life, staying healthy is easier said than done. That’s why Hally® health is all about helping you live your healthiest life. Get secure, instant access to your coverage by logging in to the Hally mobile app or hally.com. Manage your health plan and get the care you need anytime, anywhere.
On Hally.com get access to: • Exercise • The
classes, health courses and cooking demos.
Hally blog.
• Hally
Healthcast, a monthly podcast led by medical experts.
• Health
tips, coaching and information on care coordination.
• Tools
and resources for asthma, diabetes and high blood pressure.
• And
lots more.
You can also download the Hally app or sign in to hally.com to stay in the know. Scan the QR code to learn more about the Hally app. Once you log in, you get instant, secure access to your coverage anytime, anywhere.
On the Hally Mobile App you can: • See
all your account activities in one place.
• Access
your virtual ID card.
• Search
for doctors and other resources.
• Quickly • Get
connect with a doctor over virtual visits.
cost estimates.
Visit hally.com for more information, and find the Hally app on the App Store or Google Play. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
Here’s a little more info on what Hally health can do for you: Health Coaching Get help with nutrition, weight loss, staying active and more.
Virtual Health Coverage Get care when and where you need it through virtual health coverage. With the telehealth benefit, you can connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. And with the virtual visit benefit, you can connect 24/7 with a board certified doctor or counselor by phone, secure video or our member app. Telehealth Benefit Connect with your primary care provider or specialist over the phone or online with the telehealth benefit. You can securely speak with your personal healthcare providers without having to leave the comfort of your home. Access varies by provider. Speak with your provider to determine availability. Virtual Visits Get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S. You can connect with a board certified doctor or counselor by phone or secure video through the Hally app, 24 hours a day, 365 days a year – whether you’re at home, in the office or on the go.
Get seen for 50+ conditions – physical and behavioral: • Addictions. • Allergies. • Cold/flu. • Depression • Ear
problems.
• Fever. • Grief
and loss.
• Panic • Skin
disorders.
conditions.
• Trauma.
Go to hally.com to log in and get started, or call Member Services at the number on the back of your member ID card for more information.
Quit For Life® Get help ending your tobacco use with: • One-on-one • Quit
coaching from a quit coach.
plan made just for you.
• Helpful
tools, like Text2Quit®.
• Web
Coach®, an online learning and support community.
Go to HealthAlliance.org/Quit-For-Life for more information.
Your Perks and Programs Your plan is made with plenty of perks and programs to help you with your health goals.
Active&Fit Direct™ Join one of 11,000+ fitness centers nationwide for just $25 a month (plus a one-time $25 enrollment fee and applicable taxes). For more info, go to HealthAlliance.org/Active-Fit-Direct. The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit Direct and the Active&Fit Direct logos are trademarks of ASH and used with permission herein.
Acupuncture Benefit •
Treatment must be for headache, neck pain or lower back pain diagnoses.
•
You don’t need preauthorization.
•
You can choose any acupuncture provider. A per-visit copay may apply (varies by plan).
•
You or your provider should submit claims using the information on the back of your ID card.
Assist America® Get expert medical help when you’re 100 miles or more from home. Go to HealthAlliance.org/ Assist-America to learn more. Other conditions and exclusions may apply. If you have an HMO plan, all Assist America benefits do apply. Don’t forget, Health Alliance only covers your emergency care while traveling. Assist America will not pay you back for ambulance or other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away.
Student Extended Network You and your family get access to top-notch doctors and hospitals. That doesn’t have to change when your student seeks education outside our service area. Through our Student Extended Network, dependent children on your plan who leave our service area to attend an academic institution, including (but not limited to) a college/university, technical school or vocational school, can get access to the national First Health® network while in school. Your dependent student will receive a special ID card and can search the First Health® network by logging in to your Hally® account here: login.hally.com/Account/Login. All other family members on the plan will keep their current ID cards and use the standard provider network. When your child gets care in the extended network, it’s their responsibility to make sure prior authorization is received when necessary. They can call Customer Service to check whether prior authorization is needed, and if so, should ask their doctor to request it. Scan the QR code below for more information.
Your Perks and Programs (continued)
Hearing Services Get one routine hearing exam for a $75 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year. Learn more at TruHearing.com. Or you can get access to comprehensive hearing services at any in-network hearing provider (when medically necessary) up to a certain cost. See the Your Comprehensive Hearing Benefits flier for details or call Customer Service.
Preventive Care We cover preventive services and tests to keep you healthy. Here is a partial list of the services included in your comprehensive preventive service benefit.* •
One preventive service exam per member (no age limitations) per plan year.
•
One preventive service visit to a Women’s Principal Health Care Provider per plan year.
•
Well-child care.
•
The screenings, procedures and immunizations listed below, within the applicable preventive service benefit: −
Blood sugar screening.
−
Cervical cancer screening (Pap smear).
−
Cervical cancer vaccine.
−
Childhood immunizations.
−
Chlamydia screening.
−
Cholesterol screening.
−
Colorectal cancer screening (flexible sigmoidoscopy, screening colonoscopy, fecal occult blood test, including FIT).
*Office visit copayment and/or coinsurance may apply.
OTC4Me 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.
Knowing Your Costs Knowing what your health plan pays and what you may owe brings peace of mind.
Treatment Cost Calculator This tool lets you explore a wide range of healthcare treatment options, helping you potentially save money by seeing different costs. You can: • Compare
costs on procedures, facilities and doctors.
• See
in- and out-of-network cost estimates.
• Find
doctors, hospitals and clinics in your area that offer the service you need.
Explanation of Benefits After you visit your doctor or receive medical services, you get an Explanation of Benefits (EOB) showing the cost of the service, how much we paid on your behalf and the amount you may still owe.
Claims Issues Always call us first (at the number on the back of your ID card) for claims questions. We can check if the claim was properly submitted to us and whether it has been paid. We also can help you with next steps.
“Go Paperless” Go green with paperless member materials and simplify your life. • Always
available.
• Get
access to your plan materials and important information about your account anytime, anywhere.
• Less
clutter and waste.
• Avoid
mountains of mail, storing paperwork and wasted paper with online access to your plan.
• Secure
access.
• Know
your personal health information is safe from being intercepted or stolen in the mail.
For more information, visit HealthAlliance.org/Go-Paperless.
Helpful Terms Benefits
Member
The healthcare services your health plan covers: doctor visits, routine physicals, diagnostic tests, etc.
A person covered under a health plan, either the enrollee or eligible dependent.
Benefit Period
Your plan pays 100% of covered expenses for the rest of the plan year after you reach this amount. You’ll no longer pay copayments or coinsurance, just your monthly premium. Tier 1 and Tier 2 services both apply to the in-network OOPM. If using Tier 3 out-of-network services, you may need to cover costs above the OOPM.
The stretch of time your plan covers you (for example, July 1 to June 30). See your plan materials for your benefits’ start and end dates.
Contribution
The monthly premium you pay for coverage.
Coinsurance
The percentage you pay for services at a doctor’s office, pharmacy or hospital.
Copay
The set fee you pay each time you use a medical service covered by your plan.
Deductible
The amount you pay before your benefits kick in. Some plans have separate medical and pharmacy deductibles.
Out-of-Pocket Maximum (OOPM)
Prior Authorization
A review process your doctor must request for a specific drug or service to make sure you meet certain requirements before the health plan agrees to cover it. See page 4 for more information.
Primary Care Provider
A personal doctor (or advanced practice provider) you choose to oversee your care.
Telehealth
Dependents
Remote healthcare you get from a primary care provider or specialist over the phone or online.
Formulary
Customer Service
Children or a spouse covered on your plan.
A list of drugs covered by your plan, including generic and brand-name drugs. Log in at hally.com or on the Hally app to find your plan’s list of drugs.
Generic Drugs
Drugs with the same active ingredients as the brand-name versions reviewed and approved by the Food and Drug Administration (FDA). They cost less because their makers don’t have to spend money on research, development and marketing.
(800) 851-3379 (TTY 711) Weekdays 8 a.m. to 5 p.m. HealthAlliance.org
Notes
Notes
3310 Fields South Dr. Champaign, IL 61822 HealthAlliance.org
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