Faculty & Staff
Risk & Benefits Management
Frequently Asked Questions
Why Methodist PPO and not Proctor or OSF?
All three providers were invited to present preferred providers options. Methodist's proposal offered ICC the greatest cost savings. In addition, 68% of all health care dollars ICC expends currently are spent at Methodist. This means that as a percentage, more ICC employees already are choosing this provider for care.
Can I switch to the other plan option if I change my mind?
You switch plans only at the annual pre-determined enrollment session set by the Plan Administrator
Do I have to change my personal physician if I choose the Methodist PPO option?
No, the Methodist option only applies to inpatient and outpatient services-not physician office care. You may continue to see your current physician, but any services performed by a hospital, including things like surgeries, X-rays, lab test, etc., need to be done through Methodist. If your physicians in the greater Peoria area admit to all local hospitals.
Do I still need to use the Consumer Care booklet and do Reasonable and Customary (R&C) charges still apply?
Yes, you will need to continue to use the booklet to receive maximum benefit. Benefits are still paid based on reasonable and customary charge determinations.
What if there are services that I need that are not performed at Methodist Medical Center or what if my physician prefers another hospital?
There are only a few services offered at Peoria hospitals that are not offered at Methodist. If a service is not offered at Methodist, but is offered at OSF or Proctor, Mutual Medical will consider authorizing an exception and the services would be covered under the same rates as at Methodist. If your physician prefers Proctor or OSF, but the service if offered at Methodist, you may choose not to go to Methodist, but you will pay out of network rates. In network rates pay for 90% of your hospital charges, and Methodist absorbs your co-pay. Out-of-network rates pay only 50% of your hospital charges, and you are responsible for your full co-payment.
What if there is an emergency and I am transported to OSF because of my level of trauma or I am transported to Proctor because I am incapable of designating my preferred provider?
In a life-threatening emergency, coverage at the in-network rate would extend to the facility to which you are taken by the emergency personnel. However, as soon as your condition allows, you would need to be transferred to Methodist to receive in-network coverage. Mutual Medical will be involved in that process.
What if I'm traveling or live far away from Methodist making it inconvenient for use?
The network restrictions under the Methodist PPO apply only to hospitals in Peoria. You are covered outside of Peoria, Including hospitals in Pekin, Bloomington-Normal, etc.
If you are admitted to OSF by emergency personnel, who makes the decision about when your condition is stable enough to move to Methodist?
Your attending physician and the medical director at Methodist Medical Center.
If you opt out of the Methodist PPO, will you still receive some benefits as a PPO member if you go to Methodist? (ie: in patient out-of-pocket picked up?)
No, you will not receive the out-of-pocket write-off nor will the College receive any discount on services rendered to you while at Methodist.
If we choose physicians at a clinic affiliated with Methodist (not a Medpointe) - Farmington Family Physicians - will we be covered the same as if we are at Methodist?
Yes, physicians are not a part of the Methodist PPO and benefits will be unchanged from the current plan.
If my doctor bills as a hospital based outpatient clinic affiliated with OSF is this OK?
Yes, as long as billed by the doctor. For example, OSF Medical Group, along with other physicians, is not consideration with the Methodist PPO.
Will birth control pills be covered?
No, drugs covered under the Plan must be for the purpose of treating an underlying cause of an illness or injury be relieving pain or preventing serious medical consequences.
Why can't an employee change from the FOC plan to the PPO anytime in the year, versus only at the annual pre-determined enrollment session set by the Plan Administrator? Wouldn't it benefit the College and the Plan to allow this type of change (FOC to PPO) at any time?
Normally, a PPO allows each participant to change their enrollment from one plan to the other annually. To allow changing at anytime could cause significant extra expense for the plan in that participants could opt to change from the PPO to the FOC for the period when they are in need of health care (ie: birth of a child, elective surgery, etc.) and they prefer to go to the FOC hospital. The Plan would not receive discounts at a FOC hospital which could be significant. On the other hand, the plan participants would only pay an additional premium for a short period of time until such time that they wanted to switch back to the PPO. Also administratively, it would be extremely difficult, if not impossible, to coordinate monthly payroll deduction changes, individual plan status changes, TPA notification, etc.
Will the annual pre-determined enrollment session allow employees who are not currently in the ICC health plan to join the plan at that time? What about the employees who are in the supplemental, wrap around plans?
There will not be an open enrollment period for those employees who are not already a participant in the health plan. However, if you lose other coverage on yourself or dependents due to divorce, death of a spouse or loss of employment, you can apply for single or family coverage within 30 days of such occurrence and have coverage effective the date you complete the enrollment form. A PPO participant who qualifies for coverage under the supplemental or wrap plans will be allowed to enter either plan at any time. They are required to remain in the optional plan until January of the next year.
The Methodist Managed Care Agreement says that if an employee who is in the Methodist PPO program receives treatment at either OSF or Proctor for a service that is available at Methodist, the benefits differential will be 50/50 instead of the 90/10. Is it correct to say that the employee pays 10% of what the cost was originally and the 50% of the cost AFTER the 10% he or she paid, thereby making the actual employee-paid percentage 55%?
For services received out of network when the service was available in network the penalty of 50% would be applied as follows: Using an example of a $10,000 hospital bill. The hospital charges would have the 50% factor applied lowering it to $5,000. The deductible would then be applied, if not already met. If the deductible had not been met, the employee would owe $5,250 and the plan would owe $4,750. No co-insurance applies as it is met in the 50% out of network penalty. In other words the employee paid percentage is 50% subject to deductibles.
Who decides whether the service was available at methodist or not? Is it the TPA?
The FOC hospital would confirm benefits with the TPA. At that point, the TPA coordinates through the surgeon and the PPO hospital whether a procedure is available. Even once this initial determination is made with the FOC and TPA, the determination may be subject to review and approval by the College.
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