Medical home FAQ
The following are answers to commonly asked questions about the patient-centered medical home and benefits available to PEBB members when enrolled in Providence Choice.
Q. What is a patient-centered medical home?
A. A patient-centered medical home is a comprehensive approach to health and wellness that puts your needs at the center of your health care. This approach to primary care has received attention in Oregon and across the country for its potential to advance the Triple Aim goals of health reform: 1) A healthy population, 2) Extraordinary patient care, and 3) Reasonable costs.
Q. How does a patient-centered medical home achieve these three goals?
A. Patient-centered medical homes achieve these goals by focusing on all aspects of patient care. Depending on your specific health needs, focus will include wellness and prevention, coordination of care, active health management and support for individuals living with chronic conditions.
Q. What features are included in a patient-centered medical home?
A. Key features of the patient-centered medical home include:
- A dedicated primary care provider who coordinates all your health needs.
- A team of health professionals (for instance, physician assistants and mental health providers) when you need them.
- Guaranteed same-day access to care either in-person, by phone or email.
- Electronic medical records available in most clinics.
Q. Does Providence Health Plan offer a patient-centered medical home model of care?
A. Yes. When you enroll in the Providence Choice plan, you are selecting a patient-centered medical home for your health care needs.
Q. Is Providence Choice available to all PEBB members?
A. Medical homes are available in many Oregon counties and select Washington-state counties.
Q. I'm healthy. What will my experience be like as a Providence Choice plan member after I've been contacted by a member of my health team?
A. If you find that you don't need to schedule an appointment, you'll still gain important information as a result of contact with a member of your health care team. You'll know how to access care if and when you need it. You'll also learn your provider's contact information, including an email address, so you can communicate with your provider confidentially and efficiently.
If a future health need arises and you need to see a provider, you'll be an established patient with guaranteed access to the clinic. Or, if you just want to send an email to your provider, you can.
Q. I am living with a chronic condition. What will my experience be like as a Providence Choice plan member after I've been contacted by a member of my health team?
A. Here's a quote from a current Providence Choice member about her experience as a patient-centered medical home member. She lives with and manages a chronic condition:
I live with a chronic health condition and I've never felt so cared for [as I do] with my medical home. My provider works with me very closely and helps me navigate many complex treatment options. He coordinates my care when I need to see a specialist, follows up with the specialist after I receive care, and monitors my progress. Nothing falls through the cracks. I have immediate ways to communicate with my provider, from emails to office visits. I know my provider knows me and I feel very comfortable and confident that I can share thoughts and concerns and bounce off ideas. I feel completely connected. I'm an established patient.
Q. My life is pretty stable, but I could definitely improve some lifestyle behaviors. What will my experience be like as a Providence Choice plan member after I've been contacted by a member of my health team?
A. If lifestyle support needs are discovered during the outreach (e.g., tobacco use, diet issues, exercise support needs, poor sleep habits), you will more than likely be asked to schedule an appointment with a member of your health team. Together, you'll explore and determine what the best next steps are for you to help make appropriate lifestyle changes.
Q. Who makes up my health care team?
A. A health care team can include a number of health professionals and will vary depending on your unique health needs. It may include your primary care provider and medical assistant, and may also include: a case manager, a pharmacist, a diabetes educator, a behavioral health professional, a nurse, a specialist, or other health care providers as needed. The goal of this team approach is to keep you well as opposed to seeing health professionals only when you are sick.
Q. Is the patient-centered medical home an HMO plan?
A. No. A patient-centered medical home is not an HMO. In the Providence Choice medical home, you select the provider you want to work with. Together, you and your medical home provider will make decisions about the health care you need, including referrals to specialists. You do not need to get health plan approval before seeing a specialist. Your provider will refer you to a specialist who is in the Providence Choice network, allowing you to use your in-plan benefits. You may also see a provider who is outside of the Providence Choice network and use your out-of-plan benefits. It's up to you. You'll find that receiving care from, or coordinated by, your medical home has tremendous health and cost benefits, including the advantage of a team who knows you and your unique care needs. With the new medical home model, it's really you, your provider and other health team members making decisions and determining next steps about your health.
Q. Do I need to designate a primary care provider?
A. No. You do not need to designate an individual primary care provider. You do, however, need to select a medical home and communicate your selection to Providence Health Plan. (See steps to selecting a medical home.) Choosing and communicating your medical home choice enables Providence Health Plan to pay for services at the in-network benefit level, meaning your out-of-pocket costs are lower. Put simply, you pay less for care when you select a medical home and communicate that selection to Providence Health Plan.
Q. Do I need to receive my care from my medical home?
A. To maximize the benefits of being part of a medical home, ideally most of your care should be provided by the medical home you select. But you have a choice. You may receive care from medical home providers or providers outside your medical home. When you receive care from – or have your care coordinated by – your medical home, you will have many advantages. Your out-of-pocket costs will be lower and you will develop a closer relationship with a team of health professionals who have a single goal: Maintaining and or improving your health.
Q. Do I need to get a referral to see a specialist?
A. One of the roles of your medical home team is to help coordinate your care with specialists. However, if you choose to self-refer to a specialist, you may. Your care will be paid at the out-of-plan benefit level – usually resulting in higher out-of-pocket costs for you.
Q. How can I maximize my Providence Choice plan benefits and more fully experience the benefits of a patient-centered medical home?
A. To get the most from your Providence Choice plan benefits and the patient-centered medical home experience, embrace Providence Choice plan features, including using preventive care benefits, getting to know your team of health professionals, and using the tools and resources available.
Q. What do I need to do to start participating in Providence Choice?
A. To get started and make the most of you Providence Choice Plan benefits, you must 1) Select a patient-centered medical home and 2) Communicate your selection.
Q. How can I let Providence know my medical home selection?
A. There are a number of ways to let Providence know your medical home, so you can maximize your plan benefits. Find out how.
Q. Can I select a medical home for my spouse or domestic partner?
A. No. A spouse or domestic partner must select his or her own medical home.
Q. Can I select a medical home for my enrolled dependent?
A. Yes. Subscribers and or spouses or domestic partners may select their enrolled dependent’s medical home.
Q. Does everyone in my family need to have the same medical home?
A. No, but you do need to declare a medical home for yourself and each person covered on your medical plan. You can all choose the same medical home, or you can each choose a different medical home. It's up to you and your family members to choose what's best for each of you.
Q. What happens if I don't communicate my medical home selection?
A. If you or any Providence Choice plan member does not communicate a medical home selection, covered services will be paid at the out-of-plan benefit level, which means that you'll pay higher costs for services you receive.
Q. What if I am currently receiving care at a designated Providence medical home but have not communicated my medical home selection to Providence Health Plan?
A. If a member does not communicate his or her medical home selection to Providence Health Plan, covered services will be paid at the out-of-plan level – a more expensive level – even if you are receiving care from a designated medical home. Please be sure to communicate your medical home choice to Providence Health Plan as soon as possible.
Q. If I select a Providence Choice plan – the patient-centered medical home -- what are the specific advantages I'll receive?
A. As a Providence Choice plan member, you'll enjoy:
- Choice among more than 275 medical homes conveniently located throughout Oregon and counties in southwest Washington state
- A team of health professionals that are devoted to your unique health needs
- Guaranteed same-day access to care either in person, by phone or by email
- Encouragement to partner with your health team and participate in health and wellness activities
- Access to a national network of providers
- Outstanding customer service and accurate claims processing
- Online tools and resources that are easy to access, use and understand
- Access to in-plan and out-of-plan benefits
Q. Where are patient-centered medical homes located?
A. Providence Choice medical homes are located throughout Oregon and southwest Washington. There are more than 275 patient-centered medical homes. They include Providence Medical Groups and many independent medical clinics, conveniently located near you work and or live.