Medical home Q&A

The following are answers to questions often asked 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.

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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.

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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 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. 

When a health need arises and you need to see a provider, you'll be an established patient with guaranteed access to the clinic. 

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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 Providence Choice member about her experience with her medical home:

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.

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Q. I could 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 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.

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Q. Who makes up the care team?

A. The team may 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.

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Q. Is the patient-centered medical home an HMO plan?

A. No. 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.

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Q. Do I need to choose a primary care provider or a medical home?

A. You do not need to choose a primary care provider. You will, however, need to select a medical home and communicate your selection to Providence Health Plan to receive in-network benefit coverage. Here's how.

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Q. Do I need to receive my care from my medical home?

A. No; however, when you receive care from – or have your care coordinated by – your medical home, 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.

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Q. Do I need to get a referral to see a specialist?

A. The medical home team coordinates referrals for you; however, you may choose to do this yourself. Be aware that care provided outside of and/or not coordinated by your medical home will be paid at the out-of-network benefit level – usually resulting in higher out-of-pocket costs for you.

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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.

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Q. Can I select a medical home for my enrolled dependent(s)?

A. Yes. Subscribers and or spouses or domestic partners may select their enrolled dependent’s medical home.

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Q. Does everyone in my family need to have the same medical home?

A. No. You are encouraged to designate a medical home for yourself and each covered dependent to ensure covered services are paid at the in-network benefit level.

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Q. If I am an established patient at a designated Providence medical home and plan to continue being seen at the clinic, do I still need to communicate that as my medical home selection to Providence Health Plan?

A. Yes. Members need to notify the plan that the clinic is their chosen medical home for benefits are paid at the in-network benefit level even if they’ve been going to that clinic under another plan. Remember, if a member does not communicate the medical home selection to Providence Health Plan, covered services will be paid at the out-of-plan level.

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