Key Documents

Accessing Healthcare

Managing Your Health

Managing Your Benefits

Accessing Healthcare Choosing a Provider To take full advantage of your healthcare benefits, you must use Plan providers who are part of the Medical Associates Health Plan provider network (unless it is an emergency). Members should choose a Plan provider who acts as the main provider of medical care. Medical Associates Health Plans does not pay for out-of-network providers without a referral from your Plan provider and prior approval from Medical Associates Health Plans. If medical services can be supplied by a provider in the Medical Associates Health Plan network, you must use these providers in order for your claims to be paid. To avoid unnecessary out-of-pocket expenses, contact our Health Care Services Department before seeking care from a non-Plan provider to be sure the proper authorization is in place. How to find a Plan practitioner If you are unsure which practitioners are in the Medical Associates Health Plan provider network, you can search the online Provider Directory. Here you will find information about their specialties, office locations, and training. Call our Member Services Department if you would like additional help in choosing a practitioner. What to do in an Emergency In the event of an emergency medical condition, go to the nearest emergency room or call 911 immediately. If you are able, go to an emergency room that is part of the Plan network. If you are out of the service area at the time of your emergency or go to a out-of-network emergency room, you need to contact Health Care Services within 48 hours or as soon as medically possible. Health Care Services will communicate with the hospital and doctor to confirm your coverage and determine the most appropriate timeframe for transfer of medical care back home. Go to your Plan provider for any follow-up care. What is an Emergency? Emergency medical conditions are defined as conditions that manifest themselves through acute symptoms of sufficient severity, including severe pain, leading a person to reasonably conclude that lack of immediate medical attention will likely result in any of the following: Serious jeopardy to the person’s health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child. Serious impairment to the person’s bodily functions Serious dysfunction of one or more of the person’s body organs or parts Conditions that require emergency care Examples of emergency medical needs are injuries and illnesses that include but are not limited to: Acute allergic reactions Acute asthmatic attacks Convulsions Epileptic seizures Acute hemorrhage Acute appendicitis Coma Heart attack Broken bones Attempted suicide Suffocation Drug overdose Loss of consciousness Any condition for which you are admitted to the hospital as an inpatient from the emergency room Out-of-Area Care When out of town on vacation, school, or business, healthcare can sometimes be required for unexpected illness or injury. As a Medical Associates Health Plan member, there are coverage considerations to keep in mind when traveling. The Health Plan only provides coverage for emergency care when you are outside your immediate hometown area. Emergency Care can be defined as “medical and health services provided in cases of life-threatening, disabling, or serious illness or injury, including severe pain which arises or worsens suddenly and which, if not treated immediately, could result in loss of life or permanent damage to a person’s health.” Routine Care, which is NOT covered outside your hometown area, includes such services as physical examinations, sports physicals, immunizations, and routine eye exams. Minor medical problems require pre-approval of coverage, such as an office visit for a sore throat or earache. We recommend that you call ahead when possible to let us determine coverage and help you locate the appropriate source of care for you. Our Health Care Services phones are answered 24 hours a day, 7 days a week.. If you experience a minor medical problem that may require attention before you return home, please do not hesitate to call the Health Care Services nurses. With the proper pre-approval from Health Care Services, coverage can be granted on a limited basis, and any necessary medical follow-up provided when you return to your service area.