Your Primary Care Physician (PCP) is the person to call whenever you need health
care. As a member of Central Health Medicare Plan, you will need to select a PCP
within our network. Not only will your PCP treat you for illness and injuries, but
your doctor will also provide routine and preventive care, and assist you with making
important medical decisions to see specialists or other services.
In addition, your PCP has referral relationships with Central Health Medicare Plan contracted providers including physician specialists, skilled nursing facilities, durable medical equipment providers and other selected providers.
You have the ability to change your PCP at anytime. If you are not happy with your doctor for any reason and want to choose a new PCP, you may always select another physician.
There may come a time when you need medical care only a specialist can provide. Whether you need to see a podiatrist, audiologist, cardiologist or another type of specialist, you want to be sure your care is covered.
In general, you must receive a referral from your PCP before you are covered to see a specialist. During your office visit, your PCP will evaluate your condition and, if necessary, refer you to a specialist in the Central Health Medicare Plan network.
By obtaining a PCP referral, you will pay only an office visit co-payment for your visit to the specialist. In most cases, if you don’t have a PCP referral to see a specialist, your visit will not be covered.
Central Health Medicare Plan reviews the care given to our members to ensure that services are being provided, or utilized, in the best possible manner.
In accordance with National Committee on Quality Assurance (NCQA) standards, employees of Central Health Medicare Plan who make or supervise utilization-related decisions base these decisions only on the clinical appropriateness of care and service. Central Health Medicare Plan does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. In addition, there are no financial incentives for Utilization Management decision makers, and Central Health Medicare Plan does not encourage decisions that result in underutilization.
Receiving Care in the Event of a Disaster or Public Health Emergency
When a state of disaster or a public health emergency is declared in our service area, you may be able to receive your normally covered care from non-contracted providers and facilities while paying the same cost-sharing as you would under a network provider or facility. In addition, you may be able to see a Specialist without a referral from your PCP if your PCP is unavailable. If we are unable to resume our normal business operations by the end of the public health emergency or state, we must inform the Centers for Medicare and Medicaid Services (CMS).
Declaration of Disaster
A declaration of disaster is recognized where the President declares a state of disaster or emergency under the Stafford Act or the National Emergencies Act. The Secretary of the Department of Health and Human Services (HHS) may also declare a public health emergency under Section 319 of the Public Health Service Act. The Secretary may authorize waivers or modifications under section 1135 of the Public Health Service Act where the President has made a declaration of disaster. Finally, the Governor of a State or Protectorate may also declare a disaster. The disaster will end when whoever declared the disaster or public health emergency declares an end to the disaster. CMS may also declare an end to the public health emergency or state of disaster. Finally, if no end date to the disaster or public health emergency was declared, the disaster period will end after thirty (30) days have elapsed.