| Who Is QualChoice? |
QualChoice is an
Arkansas based Third Party Administrator contracted to provide administrative services for
the employees health benefit program for the University of Arkansas System. QualChoice has
approximately 50,000 enrollees throughout the UA System and the state of Arkansas, making
it the second largest managed care organization in the state. As of January 1999 the
QualChoice network consisted of over 2,500 physicians and mental health providers and 57
facilities throughout the state.
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| Why
QualChoice? |
Preventive Health
Care
Depending on which plan you choose, the QualChoice program
offers preventative health care for enrollees including periodic health exams,
mammography, pap smears, well baby care and immunizations.
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Terms Used by QualChoice
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| Primary
Care Physicians |
Primary Care Physicians (PCP's) include those
practicing Family Medicine, General Practice, Internal Medicine and
Pediatrics.
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Out-Of-Network
Physicians (Only available on the
POS Plan) |
There are physicians who are not within
the QualChoice Network of physicians, but by the Out-of-Network Option
offered by QualChoice you can still utilize their care. See Health
Plan Comparison for details on Out of Network Physicians.
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| Specialists |
Specialists in the
QualChoice Network include physicians of virtually every medical specialty including
surgery, cardiology, neurology and others.
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| Referral |
As of January 1, 2004, you are no longer required to
obtain a referral from your Primary Care Physician before seeking care
from a network specialist. A referral from your Primary Care Physician
and pre-authorization from QualChoice is required in order to receive
In-Network benefits from an Out-of-Network provider.
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Classic Plan
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The Classic Plan The Classic Plan is a managed care plan, which requires you to access
care through your chosen Network Providers.
You select Primary Care Physician (PCP) from the QualChoice Classic Plan
Network prior to seeking services. You go to your PCP for regular
medical care, including preventative care. Services not provided, or
ordered or Referred by your Network Primary Care Physician or other
network specialists are not
covered. See Section Ten, Exclusions and Limitations, in your Summary
Plan Description for further information)
You file no claim forms and pay only a $20.00 co-payment at the time of
your Network Primary Care Physician or Network OB/GYN visit and a $35
co-payment at the time of your Network Specialist visit. Your Network
Provider is responsible for filing your claim.
Plan Comparison
Premiums
Basic Covered Services
Preventative and Well Child Care
Physician Office Visits
Medical Services While Hospitalized
Hospital Services
Other Services
Provided
Home Healthcare Visits
In-Patient Hospice Care
Certain Transplant Procedures
Coverage While Traveling
Mental Health and
Substance Abuse
Emergency Room
Visits
Summary of
Pre-Authorization Requirements
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This health plan provides preventative and well-child care
both of which are important parts of a total healthcare program. Preventative care
includes such services as
routine physicals for children and adults
immunizations
well-baby care
Mammograms, prostate screening and other "wellness" services
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Physician Office
Visits |
QualChoice allows
physician office visits for treatment and diagnosis, preventative care, diagnostic and
laboratory tests, and allergy treatment.
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| Medical Services while
Hospitalized - Classic |
Medical services
while hospitalized include surgery, medical visits by your doctor, obstetrical care
including examination of a newborn child, anesthesia, diagnostic imaging and laboratory
services and radiation treatments.
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| Hospital Services - Classic |
Hospital services
cover a semiprivate room, outpatient services, physical, occupational and speech therapy
and emergency room care for emergency situations.
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Other Services Provided - Classic Plan
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| Home Healthcare Visits - Classic |
Home health care is limited to forty (40) visits per
year and may include the following: intermittent skilled nursing care by
a registered nurse or a licensed practical nurse under the supervision
of a registered nurse; intermittent home health aide services when
provided in conjunction with skilled nursing or physical therapy visits;
and physical, occupational and speech therapy.
Each visit by a member of a home care team is counted as one home care
visit. Up to four hours of home health aide service are counted as one
visit. If home health care is recommended by a
non participating physician, QualChoice must approve this in advance.
This approval may be secured by calling a QualChoice case manager at
1-501-228-7111 or 1-800-235-7111
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Hospice Care -Classic |
QualChoice will pay for up to six months
of hospice care that is authorized by your network physician and
provided by a hospice that possesses all licenses, certifications,
permits and approvals required by applicable state and local law.
Inpatient care in a freestanding hospice, a hospice unit
within a hospital or skilled nursing facility, or in a regular hospital
bed; home care services provided by the hospice either directly or under
arrangements with other licensed providers, including but not limited
to, the following: intermittent nursing care by registered nurses,
licensed practical nurses, or home health aides; physical therapy;
speech therapy; respiratory therapy;occupational therapy; Social
services; respite care; nutritional services; laboratory examinations,
x-rays, chemotherapy and radiation therapy when required for control of
symptoms; medical supplies; medical care provided by your own attending
physician or the hospice physician; and counseling and bereavement
services provided to the following family members: children; parents;
spouses; and siblings.
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| Certain Transplant Procedures-Classic |
QualChoice will pay for Covered
Services for transplant procedures as approved by Medicare. If you need
a transplant, or if you elect to be a donor for someone who requires a
transplant, pre-authorization is required. The transplant is subject to
pre-authorization by QualChoice/QCA. Your Network Physician must CALL
QUALCHOICE/QCA at (501) 228-7111 to obtain our authorization prior to
your evaluation for transplant potential and placement on any transplant
list. Once the evaluation is complete, pre-authorization for the
transplant procedure must also be obtained. QualChoice/QCA will
coordinate all transplant services, including evaluation and transplant.
Failure to coordinate all transplant related services with QualChoice/QCA
may result in non-payment of these services.
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| Coverage While Traveling - Classic |
If you have an accident, unforeseen
illness or injury that requires immediate care when you are away from
home (outside the Service Area), you may seek Emergency care at the
nearest health care facility.. This does not include care that you could
foresee before leaving the Service Area. If you access non emergency
care while outside of the Service area the medical expenses incurred at
that time will not be covered. You must notify QualChoice within
forty-eight (48) hours, or as soon as physically possible, any time you
require Emergency care.
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| Ambulance and Emergency Room
Visits - Classic |
You must pay a $100.00
copayment for emergency care. If you are admitted to the hospital at the time of the
emergency room visit, the copayments will be waived.You must notify QualChoice within
forty-eight (48) hours, or as soon as physically possible, any time you require Emergency
care.
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| Mental Health and Substance Abuse
-Classic |
Inpatient Care is
limited to 10 days per calendar year, outpatient services limited to 10 visits per year.
Lifetime benefit for inpatient services is limited to 90 days.
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| Summary of Pre-authorization
Requirements for Mental Health Substance Abuse |
For services, your Network Provider must call QualChoice at 800-235-7111 for pre-authorization for care in the following circumstances:
After the initial outpatient evaluation visit, the provider
of care is required to submit a treatment plan for pre-authorization of any additional
visits prior to the visits occurring.
Prior to any psychological testing performed by any
provider on an outpatient basis or while you are an inpatient at a non-participating
facility.
Prior to any admission to a hospital, inpatient facility,
or partial hospitalization unit or within 48 hours of any Emergency inpatient admission.
Note: Some services may require Pre-authorization.
Please refer to the Summary Plan Description Section Seven (Mental Health and Substance
Abuse) and Section Eight (Procedures for Pre-authorization) for details.
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Point of Service
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| POS
In Network Option |
The In-Network Option is the least
expensive option in the Point of Service(POS) Plan. You select a Primary
Care Physician (PCP) from the QualChoice (POS) Network. You go to your
PCP for regular medical care, including preventative care.
You file no claim forms and pay only a $25.00 co-payment
at the time of your Primary Care Physician or Network OB/GYN visit and a
$35 co-payment at the time of your Network Specialist visit. Your
Network Provider is responsible for filing your claim.
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| POS
Out-Of-Network Option |
The Out-of-Network Option allows you to
visit any doctor or hospital you wish even if the doctor or hospital is
outside the QualChoice Network. You are still covered under the
QualChoice plan, but you must file your own
claim form and services
may be subject to program approval . You will pay more of the
out-of-pocket expenses, based on usual and customary fee schedules.
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Covered Services - Point of Service Plan
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| Physician Office Visits - POS |
QualChoice allows
physician office visits for treatment and diagnosis, preventative care, diagnostic and
laboratory tests, and allergy treatment.
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| Preventive and Well-Child Care - POS |
This health plan
provides preventative and well-child care both of which are important parts of a total
healthcare program. Preventative care includes such services as
routine physicals for children and adults
immunizations
well-baby care
Mammograms, prostate screening and other "wellness" services
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top
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| Medical Services while
Hospitalized - POS |
Medical services
while hospitalized include surgery, medical visits by your doctor, obstetrical care
including examination of a newborn child, anesthesia, diagnostic imaging and laboratory
services and radiation treatments.
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| Hospital Services - POS |
Hospital services
cover a semiprivate room, outpatient services, physical, occupational and speech therapy
and emergency room care for emergency situations.
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Other Services Provided - Point of
Service Plan
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| Home Healthcare Visits - POS |
Home health care is limited to forty (40) visits per
year and may include the following: part-time or intermittent home
nursing care by or under the supervision of a registered nurse;
part-time or intermittent home heatlh aide services that consists
primarily of caring for you under the supervision of a registered nurse;
physical, occupational or speech therapy if provided through a home
health agency; and skilled treatments performed by licensed or certified
home health agency personnel, including the non-prescription medical
supplies and drugs used or furnished during a visit by home health
agency personnel. Non-prescription medical supplies may include surgical
dressings and saline solutions, but do not include prescription drugs,
certain intravenous solutions and insulin. Each
visit by a member of a home care team is counted as one home care visit.
Up to four hours of home health aide service are counted as one visit.
If home health care is recommended by a non participating
physician, QualChoice must approve this in advance. This approval may be
secured by calling a QualChoice case manager at 1-501-228-7111 or
1-800-235-7111.
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Hospice Care - POS |
Covered medical services include
hospice care authorized by your physician during the period when the
hospice admits you to its program. Specified covered medical services
include hospital care, organ procurement, pre-operative care, and post
operative care. You, or someone doing so on your
behalf, must call QualChoice at 1-800-235-7111 to obtain
pre-authorization of Transplant Services, including the evaluation to
determine if you are a candidate for transplant by any transplant
program. Pre-authorization is required to avoid a potential denial of
Benefits.
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| Coverage While Traveling |
If you have an
accident, unforeseen illness or injury that requires immediate care when you are away from
home (outside the Service Area), you may seek Emergency care at the nearest health care
facility. The Plan will pay Option 1 Benefits. This does not include care that you could
foresee before leaving the Service Area. You must notify QualChoice within forty-eight
(48) hours, or as soon as physically possible, any time you require Emergency care.
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| Ambulance and Emergency Room Visits |
You must pay a $100.00 copayment for emergency care. If you are admitted to the hospital at the time of the
emergency room visit, the copayments will be waived.You must notify QualChoice within
forty-eight (48) hours, or as soon as physically possible, any time you require Emergency
care.
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| Mental Health and Substance Abuse -
POS |
Inpatient Care is
limited to 30 days per calendar year, outpatient services limited to 30 visits per year.
Lifetime benefit for inpatient services is limited to 90 days.
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| Summary of Pre-authorization
Requirements for Mental Health / Substance Abuse |
For any option, you or the provider of service must call
QualChoice at 800-235-7111 for pre-authorization for care in the following circumstances:
After the initial outpatient evaluation visit, the provider
of care is required to submit a treatment plan for pre-authorization of any additional
visits prior to the visits occurring.
Prior to any psychological testing performed by any
provider on an outpatient basis or while you are an inpatient at a non-participating
facility.
Prior to any admission to a hospital, inpatient facility,
or partial hospitalization unit or within 48 hours of any Emergency inpatient admission.
Note: Some services may require Pre-authorization.
Please refer to the Summary Plan Description Section Four (Mental Health and Substance
Abuse) and Section Eight (Procedures for Pre-authorization) for details.
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Point of Service
Alternate Plan
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Point of Service Alternate Plan
Only available to Out
of State Employees and Retirees.
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