Why a Patient Centered Medical Home Model for My Health Plan

By Editor Guest on May 3, 2018
Posted in Latest Updates

Healthcare doesn't have to be confusing. That's why we've put together a monthly e-series!

This month learn more about the Patient-Centered Medical Home (PCMH) and everything you need to know about referrals. 

Why a PCMH Model for My Health Plan

It starts with you, the patient.

A Patient-Centered Medical Home (PCMH) allows for you to take control of your healthcare outcomes by building solid relationships with the providers that care for you. This unique model has shown to improve the quality of care you receive which keeps you healthier, longer.

Team Approach
In the center of your home, you and your PCP lead the charge when it comes to adding additional providers. Whether it is a specialist, pharmacist, dietitian or health coach, you will both make decisions together regarding your health journey. Anyone on your expanded team will be in communication with your PCP to ensure a constant flow of information regarding your healthcare needs and care plan.

Healthcare Advocates
Healthcare advocates are ready to work hand-in-hand with you when you need that extra hand coordinating office visits or finding a new provider in your area. They are able to assist you in finding the right provider for you or your family during your entire health journey. Healthcare Advocates are also there to help assist with access issues with appointment scheduling and help you get the right care at the right time.

Virtual Care
Virtual care, or telemedicine, is available via MDLive 24 hours a day, 7 days a week at no additional cost to you. Telemedicine fills the gap in availability and offers convenience when your PCP is not immediately available for non-acute situations. Additionally, telemedicine gives you a cost-saving option if you are considering an urgent care or emergency room visit for an issue that you already know to be non-emergent. After your virtual visit, it's important to obtain a summary to share with your PCP, so he/she is able to carry out the care plan discussed and update your medical records with the visit.

Care Coordination
Your providers work closely together to ensure your care is coordinated and each provider in your medical home is aware of your care plan.

Everything You Need to Know About Referrals

Referrals are the key to care coordination, working to make sure that you receive the right care by the right provider. It takes the guesswork out of which specialist you should see. Referrals are also important so your PCP can ensure all specialists and other members of your PCMH are fully aware of all your care outcomes and care plan outside of their office. The benefit of obtaining a referral has often been over-shadowed with feelings of frustration because it takes additional time to see a provider in order to seek care elsewhere. However, understanding why a referral is needed and what the purpose is can help ease that frustration.

What is a referral?
A referral is a medical recommendation from a PCP to a specialist physician to facilitate a more focused level of care.

Is a referral required?
While a referral from a PCP is not required, it is strongly recommended to maintain the highest quality and continuity of care. If you choose to forgo obtaining a referral from your PCP, you will experience higher out-of-pocket costs. Refer to the Teachers Health Trust plan document for a detailed breakdown of costs.

What is the value of a referral?
A referral intends to ensure that a PCP is involved in the entirety of each participant's healthcare journey to better coordinate the care. The PCP will be able to have transparent oversight on keeping participants' in-network when referring to specialists.

Once my PCP generates a referral, what are the next steps?
Once your PCP has generated a referral, you will receive notification that the referral has been placed. It is your responsibility to schedule the appointment with the specialist and before your next appointment ensure the referral is in place.

Do I need a referral to see behavioral health specialists?
No. You can contact the therapist of your choice to schedule directly. Be sure to call Human Behavior Institute Network to ensure that the provider you wish to see is an in-network therapist. You can also visit www.hbinetwork.com to search the provider network directory to verify. Some behavioral health services require prior authorization, which you can obtain through your in-network therapist. Please review page 46 of the Plan Document for all services requiring prior authorization.

If someone has a true emergency, will they be penalized for not obtaining a referral from the primary care physician?

In the event of a true emergency, no referral is required for medical care. For the propose of coverage, a true emergency is defined as seeing a physician in connection with an unforeseen injury or illness that could lead to serious physical impairment or death if care is not received immediately. Please review page 44 of the Performance Plus Plan Document for more information on the referral process.