For Members of HIP Prime^®POS, HIP Choice Plus and HIP Choice Plus Direct

For Parents of Child Health Plus Members

For Medicaid and Family Health Plus Members

For Members of HIP Prime^®,HIP HMO and HIP HMO Direct

For Members of HIP Prime^®POS, HIP Choice Plus and HIP Choice Plus Direct

For Members of HIP VIP^®Medicare Plan

For Members of HIPaccess I and HIPaccess II

What is the New Member ID/NMI?

1. What's the role of my Primary Care Physician?

Your Primary Care Physician (PCP) is your personal physician. To receive maximum benefits under your plan, you will want to have your PCP provide your health care or refer you to specialists when you need specialty services. Getting care through your PCP also helps assure that your care is coordinated by a physician who knows any health problems you may have.

Look on your HIP Identification Card. Your PCP's name and phone number are printed on the front of the card. If the name that appears is not the PCP you selected, or if no name appears, you can select or change your PCP online. Begin by doing a Provider Search. Then, Log In and follow the instructions for selecting or changing your PCP. If you need help, call HIP's Customer Service line at 1-800-HIP-TALK (1-800-447-8255).

2. Do I call my PCP in an emergency?

Yes, unless it's a life-threatening emergency. In a life-threatening emergency, you should call 911 and get the help you need immediately. In non-emergency situations, call your PCP for the help you need. Keep in mind that your plan does not cover use of hospital emergency rooms for non-emergency care — that is, for care that does not match the definition of a life-threatening emergency given in the answer to Question 3 below.

3. What constitutes an emergency ?

An emergency is a medical or behavioral condition that comes on all of a sudden, and has pain or other symptoms. The condition must be one that makes a person with an average knowledge of health fear that you or someone will suffer serious harm to body parts or functions or serious disfigurement without immediate care.

Examples of emergencies are:

• A heart attack or chest pain.
• Bleeding that won't stop.
• A bad burn.
• Broken bones.
• Trouble breathing.
• Convulsions.
• Loss of consciousness.
• When you feel like you might hurt yourself or others.
• If you are pregnant and have pain, bleeding, fever or vomiting.

Examples of non-emergencies are colds, sore throat, upset stomach, minor cuts and bruises or strained muscles.

4. What happens if I go to see a specialist without a referral from my PCP?

In most cases, if you go directly to a physician without a referral from your PCP, you will have higher out-of-pocket costs. Check your Summary of Benefits or Schedule of

Benefits for an overview of these costs. There are a few exceptions. For example, higher costs will not apply to the following services from HIP participating providers: *

• Chiropractic treatment.
• Primary and preventive care from your PCP.
• Primary and preventive OB/GYN care, including mammography and cervical screenings.
• Outpatient treatment of mental illness.
• Refractive eye exams from an optometrist.

* Subject to the terms of your Contract or Certificate of Coverage.

5. Will my PCP give me a referral to any doctor in the HIP participating network?

You can expect your PCP to refer you to specialists that he or she knows and trusts. In most cases, that means referrals to other physicians within the same medical center or medical group to which your PCP belongs. The exception is when the kind of care you need is not available from within the PCP's usual referral group. In that case, the PCP will find a qualified physician from the full HIP network to treat you.

It's important to remember that all physicians develop these kinds of referral patterns. That's true regardless of their participation with HIP or with any other health plan. And this practice is very much in your best interest. When the PCP coordinates all your care, you are protected against such problems as conflicting medications or duplicate procedures. These kinds of problems can occur when you are referring yourself to more than one physician.

If you want to go to a physician without a referral, your plan will provide coverage subject to the requirements noted in your Summary of Benefits or your Schedule of Benefits. The requirements are also described in Point-of-Service Coverage in your Member Handbook, under Information About Your Coverage.

6. Do I have to get prior approval from HIP before getting care?

There are two answers, depending upon whether the care is referred by your PCP or not.

• If you receive care from your PCP, or through referral from your PCP, the PCP will get any necessary approvals for you. (Sometimes the specialist may secure the approval instead.) Only certain services require prior approval. They are:
• All non-emergency inpatient hospital admissions, including hospital and nursing home care, rehabilitation, mental and behavioral health treatment, or skilled nursing facility care.
• Ambulatory surgery, except termination of pregnancy (in a hospital setting or freestanding surgical center).
• Air ambulance.
• Non-emergency land ambulances.
• Home health care (nursing, physical therapy, occupational therapy, speech therapy and infusion therapy).
• Durable medical equipment (DME).
• Transplant evaluation and services.
• Hospice care.
• Outpatient diagnostic radiology services.
• Outpatient cardiac and pulmonary rehabilitation.
• All services provided by any non-participating provider/facility, except dialysis.

Even though your PCP or specialist will handle the request for prior approval, it’s a good idea to verify that the approval was actually obtained. Check with the office staff of the doctor who is recommending the care. (It’s also a good idea to call the office of any doctor you’ve been referred to for confirmation that he or she still participates in the HIP network.)

• If you choose to receive the services listed above without a referral, you will have to notify HIP and receive written approval to assure maximum benefits.

Even though your PCP or specialist will handle the request for prior approval, it’s a good idea to verify that the approval was actually obtained. Check with the office staff of the doctor who is recommending the care. (It’s also a good idea to call the office of any doctor you’ve been referred to for confirmation that he or she still participates in the HIP network.)

If you choose to receive the services listed above without a referral, you will have to notify HIP and receive written approval to assure maximum benefits.

7. How long should it usually take to get an appointment with a HIP participating physician?

We realize that when you decide to see a doctor, you would like an appointment right away. In emergencies or urgent situations you can get appointments immediately or within 24 hours as needed. Because all doctors’ offices have to set priorities by level of urgency, please be patient when it takes a little longer to get an appointment for more routine care. And please try to call well in advance to schedule your annual complete physical exam, which requires a longer appointment than usual.

Please also understand that your doctor may not be ready to see you right on time. Emergencies and urgent situations arise frequently for physicians, and even the best-planned schedules can be unavoidably disrupted as a result.

8. If I have more questions, where do I go for help?

If you have a question or concern about your HIP membership, you can contact Customer Service via e-mail and expect a response within 48 hours. Or, if you prefer to speak directly with someone by phone, Customer Service Advocates are available Monday through Friday, 8 am to 6 pm. If you have a hearing or speech impairment and use a TDD, please call 1-888-HIP-4TDD (1-888-447-4833) Monday – Friday, 8:30 am – 5 pm.

Important Note: HIP has arranged for certain administrative functions to be handled by provider organizations. As a result, you may have some different contact points.

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