The BlueCross BlueShield of Illinois HMO and PPO Plans
You have the choice of either the BlueCross BlueShield HMO or the BlueCross BlueShield PPO. You may select either of these plans for yourself and your eligible family members. Please review the descriptions below of the HMO and PPO medical plan models to assist you in selecting the plan that most suits your needs. To view the plan Summaries of Benefits and Coverage, please click on BCBS Plans.
Enrolling in the HMO Plan
If you choose the HMO plan, you will need to choose a Primary Care Physician (PCP) from the online provider directory. The medical group three-digit number and Primary Care Physician nine-digit number will need to be provided on the Enrollment Form in Section 6 for you and for your enrolling family members. Please click on Provider Directory Info for information on locating an HMO medical plan PCP, or a specialist if you enroll in the PPO plan. It is not necessary to choose a PCP when you enroll in the PPO plan. You may choose your physician at the time you seek services.
Accessing the University of Chicago Medical Center (UCMC)
If you desire to seek your services from a physician located in the University of Chicago Medical Center, you will need to choose the PPO medical as your health plan. The UCMC is not a provider in the HMO network.
Accessing Behavioral Health Services
If you choose the HMO as your desired benefit plan and wish to seek services from a behavioral health services provider, you will need to work through your Primary Care Physician (PCP) or Independent Physician Associations (IPA) for referrals for both Mental Health and Substance Abuse. Please contact your PCP for further information.
If you choose the PPO as your desired benefit plan, you may seek services either in-network or out-of-network. However, the best benefit coverage is available through in-network PPO providers. PPO Providers can be found via the online Provider Finder. Please click on Provider Directory Info for instructions on finding the behavioral health services provider of your choice.
Protected Health Information (PHI) Authorization Form
There may be instances when you will need a representative from Garnett-Powers & Associates to assist you with claims or billing inquiries for you or your enrolled dependents. In order for a representative to intercede on your behalf with an insurance carrier or health care provider, you must complete a Protected Health Information (PHI) Authorization Form. Due to the Health Insurance Portability and Accountability Act of 1996, we are not allowed to assist you unless you have completed the form. If you do require assistance, please click on the link, complete the form, and either email it to PRBP@Garnett-Powers.com or fax to 949-583-2929.
Use Your Smartphone to Find Doctors or Facilities and Access Claims Information
With the new BCBSIL App, you can order ID cards, get coverage information, find providers and more. Please click on Mobile App to register and use this service.
BlueCross BlueShield of Illinois offers a variety of wellness programs to help you attain maximum health benefits for you and your family. Please click on Wellness Benefits for more information on these valuable programs.
Discount Vision Plan
Offered through BlueCross BlueShield (BCBS) of Illinois
Both the medical HMO and medical PPO available through the PRBP offer you a vision exam copay so you may obtain a vision exam from your selected physician. If you have enrolled in the voluntary VSP vision plan offered through the PRBP, you may use this discount plan to obtain a second pair of contacts or glasses at a discount..
To compliment this benefit, BCBS offers you a discount vision plan where you may take your prescription for lenses to one of the Davis Vision providers to save on eyeglasses, contact lenses and accessories.
Please click on Plan Benefits for detailed information on the discounts available and how to locate a provider.
Health Care Reform and Your Medical Plans
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010. The law mandates certain modifications to all medical plans, and your plans were modified to comply with the law beginning on January 1st, 2011, and every year since then when modifications were necessary. To learn how your plans have been modified, please click on Health Care Reform and Your Medical Plans.
In order to better understand the changes incorporated for compliance, please click on BCBS Plans to access the benefit summaries for both the HMO and PPO. For premium rate information and contribution amounts, please click on 2015 Monthly Rates/Contributions.
Descriptions of Medical Plan Models Offered
Following are brief descriptions providing information regarding the HMO and PPO plan models available. Please read these so you may gain an understanding of the fundamental differences between the HMO and PPO.
What is an HMO Plan?
- This plan offers a broad spectrum of benefit coverage with a higher degree of managed care
- Under the Health Maintenance Organization (HMO) model, the member chooses a Primary Care Physician (PCP) contracted with the HMO plan at the time of enrollment
- The PCP becomes the gatekeeper of that member's healthcare needs
- If the member is in need of treatment from a Specialist or is in need of an In-Patient or Outpatient procedure, he/she must obtain a referral from their PCP prior to any type of consultation or treatment. If the referral is not obtained, no benefits will be paid
- There is no Out-of-Network benefit
- In the event of a life/limb-threatening emergency, the member should dial 911 and all medical care will be covered. Once the patient is stabilized, the HMO will require that the patient be transferred to an In-Network facility
- HMO premiums as well as the out of pocket expenses (i.e. deductible, co-payments, etc.) tend to be lower than their PPO counterpart due to the contractual element of capitation.*
What is a PPO Plan?
- The Preferred Provider Organization (PPO) offers much more flexibility and choice than the HMO plan
- Under the traditional PPO plan, the member does not have to choose a Primary Care Physician (PCP) at the time of enrollment
- There is an In-Network and Out-of-Network component
- The In-Network benefits (deductible, coinsurance, etc.) will be greater than the Out-of-Network benefits
- At the time of service, the member has the ability to seek care from a Specialist, without having to obtain a referral from a PCP
- The contractual agreement between the PPO Plan and the Provider is on a discounted fee for service basis. This means that the provider who participates in the network has agreed to provide their service on an agreed upon discounted fee. The Provider who is not in the network will not agree to that discounted fee and will typically charge a Reasonable and Customary fee. There is no capitation in a PPO contract
- PPO premiums tend to be higher than the HMO premiums due to the method of reimbursement and contractual agreements with the providers. Over the last few years, the difference in this pricing has diminished somewhat, but the PPO tends to still be more expensive.
* Capitation: The PCP is compensated by the HMO plan in the form of a monthly capitation fee for each member that signs up with him/her at the time of enrollment. The PCP has agreed to provide all primary care, as well as the cost for most Labs & X-rays for that capitated fee. Additionally, in the event that the PCP provides a referral to a Specialist, the PCP will pay the Specialist from that same capitation. Hospital charges and some Lab & X-ray procedures are typically paid outside of capitation.
Garnett-Powers & Associates is pleased to offer a Customer Service Representative who will assist you with benefit and enrollment questions. We will return your call or answer your email within 24 hours. Please address your questions to:
We thank you for the opportunity to be of service to you and your family.
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