Medical Home Program

PEIA offers a voluntary Medical Home program for members of the PEIA PPB Plans.

Medical Home is a concept that has been adopted and embraced by both the American Academy of Family Physicians and the American Academy of Pediatrics. Both organizations, as well as the prevailing literature, agree that providing a Medical Home for patients improves the quality and continuity of care. The Medical Home physician has the following responsibilities:

Coordinate and maintain continuity for all member health care needs, including specialty care, although the medical home does not serve as a gatekeeper. Provide acute, chronic and preventive care based on nationally accepted evidence-based medical guidelines and clinical decision support tools. Respect the member and include him/her in decisions regarding care. Inform the member in clear, understandable terms about the diagnosis, treatment options, and prognosis. Provide instructions for member to access after-hours care, as appropriate Properly document visits and maintain medical records Collect the applicable co-pay and deductible under the PPB Plan at the time of service. Read and understand the benefits, limitations and exclusions of the PEIA PPB Plan. Provide notification, in reasonable timeframe, to the member and Wells Fargo when Medical Home retires, changes physical location, or withdraws from the Medical Home Program

As an incentive for participation in the Medical Home program, PEIA PPB Plan members will pay a lower copay for visits to their named Medical Home physician. The PEIA member will have the following responsibilities:

To understand that a medical home is both a philosophy and an approach to health care
Establish and maintain open, honest communication with the Medical Home physician and staff
Be courteous to the Medical Home’s staff and show respect for the Medical Home
Provide necessary information concerning health conditions and care to the Medical Home
Seek information about wellness and health conditions and participate in decisions about health care
Follow instructions and guidance given by the Medical Home
Keep appointments or promptly notify the physician’s office when an appointment needs to be changed
Present a valid PEIA PPB Plan ID Card at appointments; and never lend the ID card to another person
Pay required co-pays and deductibles under Plan to the provider at the time of service
Always contact the Medical Home first for medical care unless it is an emergency or requires urgent care.
Notify the Medical Home within 24 hours or as soon as reasonably possible after receiving emergency care services.
Consult with the Medical Home before seeking any specialty physician service
Choose in-state health care providers when specialty care is recommended by the Medical Home
Read and understand the PEIA Summary Plan Description (SPD) and other materials concerning PEIA benefits, limitations and exclusions

PEIA raised the specialist office visit copayment to $20 per visit for all PEIA PPB patients to encourage members to name and use their Medical Homes. The Medical Home physician will not act as a gatekeeper and will not have to provide approval or make referrals for specialist visits. Members will still have free access to providers as they have had in the past.

Here’s how the process will work over the next few months:

Wells Fargo TPA will enroll participating physicians, and add them to PEIA’s directory of Medical Home Providers, indicating whether or not they are accepting new patients.
In October, we mailed an enrollment form and Medical Home directory to each PEIA PPB Plan member, allowing them the opportunity to name a Medical Home.
In December, Wells Fargo TPA mailed each participating physician a listing of the PEIA PPB Plan members who have chosen that physician as their Medical Home. If the physician is not accepting new patients, this will be opportunity to notify Acordia National if any of the PEIA members listed are not established patients.
Wells Fargo TPA will also mail a Medical Home ID card to the member. The Medical Home ID card will not replace PEIA’s standard ID card, but will simply identify those patients who have chosen a Medical Home
Beginning January 1, 2007, physicians will serve as Medical Home for the patients on the lists received from Wells Fargo TPA. The policyholder will pay a $10 copayment for every office visit with the designated Medical Home physician, and PEIA will pay the balance, up to our allowed amount.
On a monthly basis the physician will receive, by fax or e-mail a listing of any changes to the Medical Home member list. The patient will be permitted to change Medical Homes once during the plan year, upon request.
Each year during open enrollment, the member will have the opportunity to name a Medical Home.

Here is more information:

Medical Home Program Documents and Forms