Scott & White Health Plan

Accessing Care

Primary Care

When you become a SWHP enrollee, you select a Primary Care Physician (PCP) from one of the primary care areas. Your PCP is responsible for coordinating your medical care and the delivery of your health care services. Selecting a PCP is a personal decision and requires evaluating your personal health care needs. Location, specific type of care needed, availability, and access to your PCP are important factors to consider when selecting your PCP. Your PCP will help in providing your primary care, from physicals to treatment of illnesses. If your PCP feels you need the care of another specialist, he/she will arrange a referral to a SWHP network specialist. The purpose of your PCP is to encourage you to build a long-term relationship with one physician so you may become partners in your health care. Your PCP will provide efficient access to the services you will need and will take care of you on an ongoing basis. Physicians accepting the role of a PCP are prepared to provide urgent care and coordination of care whenever necessary. As a group/network model HMO, this care may be provided by others in his/her clinic or office when he/she is not available. When you have selected your PCP, contact a Customer Service Advocate at a SWHP office near you. If you need assistance with the selection of, or would like to change your PCP, contact a Customer Service Advocate at a SWHP office near you. You may select a PCP from one of the following primary care areas:

• Family Medicine - Family medicine physicians are specialists in the common health care problems that affect an entire family. Care is provided for patients of all ages - from newborns to the elderly. A typical family medicine practice includes diagnosis and treatment for acute and chronic illnesses, routine physicals and preventive care, including routine obstetric care with prenatal visits and uncomplicated deliveries. Family medicine physicians are located in all SWHP network locations and most offer evening and weekend appointment times for urgent care needs.
   
• Community Internal Medicine - Community internal medicine is staffed by general internists who are physicians that specialize in adult care. They provide primary care of both simple and complex medical problems that arise. Internists do not perform surgery, deliver babies, or take care of children under 16 years of age.
   

• Pediatrics - Pediatricians specifically provide care for newborns, infants, children, and adolescents. Working as a team with nurses, counselors, therapists, and other skilled personnel, these physicians aim to provide quality health care for this age group.

Physical Examinations

You are not required to receive a physical examination as part of your membership in SWHP. Periodic checkups or health assessments are provided to enrollees at intervals appropriate to their age, sex, and medical history. If you are a new enrollee with a medical problem that requires you to be on medication, you should contact your PCP and arrange an appointment. It is very important to make the distinction between an appointment for a medical problem or a routine checkup. There may be a waiting period for routine checkups.

Routine Appointments

To make a routine appointment, contact your PCP's office. To help the staff schedule your appointment quickly, please refer to the following:

• If it is your first appointment, indicate this to the appointment clerk
• Have your identification card ready for any required information
• Periodic examinations (e.g., annual pap smears or history and physical) may need to be scheduled 8 - 12 weeks in advance; other routine appointments are scheduled according to the urgency of the problem

• Notify your physician's office as quickly as possible if you cannot keep an appointment.

Specialty Care

All non-emergent medical care must be provided by SWHP network providers. For specialty care in the areas of OB/GYN, optometry, and ophthalmology, you may access care with the SWHP network providers for an initial evaluation without a referral. For all other areas of specialty care, a PCP refers you to a specialist to obtain care. If you see a specialist and he/she thinks you need a referral to a different specialist and/or require a procedure, your specialist should communicate his/her concern to your PCP. Except for emergency situations, your specialist does not refer you to another specialist without authorization from your PCP and/or a SWHP Medical Director. This allows your PCP to coordinate your care and prevent unneeded duplication. A referral may be limited to one visit or extended upon request by your PCP. If you have a chronic, life-threatening, or disabling condition and the approval of your PCP, you may designate a specialist as your secondary physician and see him/her without further referrals.

Hospital Admissions and Tests

For elective hospital admissions and certain types of procedures listed below, you need a prior authorization from the SWHP Health Services Division before the procedure if you want to be sure SWHP will pay for the service. Each day you are in the hospital, SWHP nurses and Medical Directors review the level of care you require with your physician and work with him/her to determine the amount of time you need to stay in the hospital. SWHP pays for urgent/emergent medically necessary admissions, but must be contacted within 24-48 hours of your hospitalization.

Examples of services, procedures, or tests that may require prior notification and/or authorization by SWHP include, but may not be limited to the following:

• Any out-of-network services
• Plastic surgery
• Behavioral health services
• Chemical dependency services
• Psychiatric testing
• Dental/oral surgery
• Laparoscopy (if for infertility services)
• Laser ophthalmologic treatment, except for retinal disease
• Cardiac/pulmonary rehabilitation
• Coronary CT angiography
• Physical Therapy (PT)/Occupational Therapy (OT)/Speech Therapy (ST) in intermediate and/or long­term care facilities
• Sleep study
• Physical Medicine and Rehabilitation
• Home Care Services: Physical Therapy (PT)/Occupational Therapy (OT)/Respiratory Therapy (RT)/Speech Therapy (ST); social services; aides
• Skilled nursing services
• Organ transplant
• Home Infusion Therapy
• Certain medications noted on formulary
• Specialty pharmacy services
• Spine surgeries
• Major joint replacements
• Long-term Acute Care (LTACH)

This list is subject to change. If you have any questions about this list or if you require an urgent coverage determination, please contact the Health Services Division at (888) 316-7947. Someone will be happy to answer any questions or concerns you may have. If you do not contact the Health Services Division prior to obtaining any of the above services, SWHP has the right to review and potentially deny coverage for the procedure or service.

Urgent And Emergency Care

SWHP will provide benefits for medically necessary emergency care whether you are temporarily out of the service area or within the service area. Emergency care is defined as the sudden and unexpected onset of a condition of such a nature that a prudent layperson, possessing an average knowledge of medicine and health, believes their health could be jeopardized if they do not get immediate treatment. SWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Some examples of emergency conditions include, but are not limited to the following:

• Unusual or excessive bleeding
• Broken bone
• Acute abdominal or chest pain
• Loss of consciousness
• Suspected heart attack
• Sudden persistent pain
• Serious burn
• Poisoning
• Convulsions
• Difficulty in breathing

In all emergency situations, you are encouraged to seek care with the nearest SWHP approved provider; however, if the time needed to reach a SWHP approved provider might endanger your health, go to the nearest emergency room. Medically necessary emergency care is covered. If you are hospitalized as a result of the emergency, you should contact the SWHP Health Services Division within 24 - 48 hours of any admission at (888) 316-7947. Coverage for continued treatment is assured when approval is obtained from the SWHP Medical Director through the Health Services Division. Emergency care in a hospital emergency room requires a co-payment, which will be waived if hospital admission occurs within 24 hours.

While a medical emergency is considered a life threatening condition; urgent care is considered less severe than an emergency, but requiring care more quickly than elective care. Urgent care includes, but is not limited to, sudden illnesses and injuries, lacerations, and fever. SWHP encourages you to access one of its urgent care centers if you find yourself needing urgent care after hours. Urgent Care Clinic hours vary at each clinic. If you do not know when to access an urgent care clinic, please contact a SWHP VitalCare nurse through our nurse advice line at (800) 975-6612.

Out-of-Network Care

SWHP out-of-network benefits are limited to accidental injuries and sudden illnesses. SWHP does not pay for out-of-network elective procedures,  or treatment for minor illness. SWHP will not assume financial responsibility for out-of-network treatment if you are well enough to return to a SWHP provider or facility.

When seeking treatment in an out-of-network emergency room, provide your enrollee identification card. This will speed up the processing and payment of your bill by SWHP. This will also allow the treating physician to discuss your emergency care with your PCP if necessary.

Optometry Care

Routine refraction examinations with participating optometrists are limited to one per enrollee per contract year and are subject to your office visit co-payment.

Routine eye exam - an eye exam by a Doctor of Ophthalmology or a Doctor of Optometry which, when within the scope of their license, includes such services as:

• External examination of the eye and its structure
• Determination of refractive status
• Glaucoma screening test

Annual Examinations for routine eye refractions are not normally required unless there is a condition leading to rapid change in the refraction characteristics of the eye. In the rare instance where a repeat refraction would be necessary in less than a year, you must obtain approval from a SWHP Medical Director to receive the care.

Behavioral Health Care

Behavioral health care is defined as care needed for treatment of emotional problems and psychiatric conditions. SWHP pays for medically necessary care that is determined to be responsive to short-term therapy. On referral by your SWHP PCP, you can access behavioral health services. Prior authorization of services is required through SWHP Health Services Division.

SWHP's behavioral health care staff includes psychiatrists, psychologists, counselors, and social workers. Benefits for behavioral health services vary widely and may be more or less limited than summarized here. Please review your Health Care Evidence of Coverage for coverage limitations and exclusions regarding your behavioral health benefits.

OB/GYN Care

SWHP encourages adult female enrollees to obtain a well-woman exam every year. Women may schedule an annual physical examination, including a pelvic exam, breast exam, and Pap smear without a referral from their PCP. Your PCP or a SWHP network obstetrics/gynecology physician may perform the exam.

Podiatry Care

A referral is needed to see a podiatrist for evaluation/consultation. Please refer to Specialty Care for the referral process. Routine foot care is not a covered benefit under SWHP unless otherwise determined by SWHP Medical Director as medically necessary.

Skilled Nursing Facility

Coverage is provided for care in a skilled nursing facility only if the enrollee is admitted to a SWHP network skilled nursing facility by a SWHP network provider and the SWHP provider certifies the skilled level of care is medically necessary. The SWHP Medical Director must determine skilled nursing care is medically necessary and approve the admission. SWHP does not cover custodial convalescent or respite care or other institutional care which does not meet the definition of skilled nursing care.

If you have any questions about your skilled nursing facility benefits, please contact a Customer Service Advocate at a SWHP office near you.

REMEMBER: All skilled nursing facility care services require both prior approvals from the SWHP Medical Director and a referral by your SWHP provider for SWHP coverage.

Nursing Home

Nursing home care is not covered under the SWHP Health Care Evidence of Coverage. SWHP does not cover custodial, convalescent or respite care in any facility. An enrollee may receive a specified outpatient treatment/service/therapy in a nursing home, if approved by SWHP Medical Director, but only the charges for the treatment/service/therapy will be covered under the enrollee's benefits. Non-covered services include, but are not limited to room and board, personal care, and comfort items. For example, an enrollee may be placed/reside in a nursing home and also placed in a "skilled bed" due to eligibility to receive physical therapy, occupational therapy, speech therapy, etc. SWHP will review requests for the skilled therapy coverage if it meets SWHP's criteria. However, the room and board, personal care, etc. would not be a covered benefit, as an enrollee could receive these same therapies at home through a Home Care Agency. Inpatient skilled nursing services are required to be provided through SWHP approved skilled nursing facility providers as outlined above.