Using Your Plan

When should you go to the Emergency Room?

If you have a serious condition—stroke, heart attack, severe bleeding, head injury or other major trauma—go straight to the nearest Emergency Room (ER). Don’t take a chance with anything life-threatening. The ER is the best place for these and other critical conditions, including:

• Chest pain
• Difficulty breathing
• Severe bleeding or head trauma
• Loss of consciousness
• Sudden loss of vision or blurred vision

Critical Care/Injury

A critical injury can happen in a moment. A MedCost registered nurse who is dedicated to your situation can help with information as you and your caregivers deal with a new and sudden health concern. Your nurse will reach out to you and provide care advocacy and participate in your care coordination. MedCost nurses are a resource for information concerning specialists, facilities and medication coverage.

Preventive Care

Well visits, annual check-ups and preventive screening tests are a part of staying healthy. Plus, these preventive measures and tests are covered under your health plan. Take advantage of preventive tests such as mammograms, prostate screenings, colorectal screenings, Pap tests and other preventive screenings recommended by your doctor.

Maternity

Pregnancy is a wonderful time. There is much to plan for from nutrition in your early trimesters to breastfeeding and pediatrician visits in the fourth trimester. Being informed about your benefits is essential as you prepare for the arrival of your baby. Once your baby arrives, don't forget to add your newborn to your health plan coverage within 30 days of their birth date.

Planning a Procedure

When you have the opportunity to plan, consider using the Cost Estimator Tool. Found in your secure Member Account, this resource compares prices and quality ratings for providers, services, hospitals, and facilities within your network and local area. Depending on the service or surgery, you may find quite a variance in price. Once you've narrowed down your options, specialist or facility, always check to see what coverage your plan offers.

Precertification

Some benefit plans include precertification requirements for certain outpatient procedures and procedures that require a hospital stay. These requirements will be indicated on your member ID card.

• If your plan has advanced imaging precertification requirements, all elective CT, MRI, and PET scans should be pre-certified.
• If your plan has comprehensive outpatient review precertification requirements, several outpatient services and surgeries/procedures, along with advanced imaging (all elective CT, MRI, and PET scans), should be pre-certified.

Either you or your doctor should call MedCost to have your procedure pre-certified. Precertification does not guarantee that your procedure will be covered, but it reduces the likelihood that you will owe additional out-of-pocket costs. A complete list of comprehensive outpatient review services requiring precertification is located at www.MedCost.com/CompOPR.

After a Procedure

Depending on the complexity of the procedure, a MedCost nurse may call to follow up to ensure you have the appropriate appointments scheduled and any necessary rehabilitation, and explain prescribed medications you may be taking. This follow-up occurs after procedures such as pre-planned back, hip, joint and cardiac surgeries. Our job is to make sure you are getting the care you need in order to make the best possible recovery.

New Diagnosis of a Chronic Condition

The diagnosis of a chronic condition introduces a lot of new information into your life. Even though you may be familiar with your plan, you will want to take a fresh look and review your benefits to note costs and coverage for your doctor and specialist visits. It is also a good idea to look at your prescription benefits to see what new medications are covered. Information on many chronic conditions is available as well as helpful information for family members or caregivers. The A-Z online library in MyCarePath is a great resource for information.

New Diagnosis of a Serious Condition

The diagnosis of a serious condition is life-altering. When such a diagnosis occurs, it is comforting to know that a registered nurse will reach out to you and be a part of your care team. This nurse is a Certified Case Manager who can help you as you look at coverage for hospital stays and specialty medications. But these care team members do more than that. They work as your advocates and participate in your care coordination, often working with family members and caregivers to provide education and best practices in care. We also offer specialized nurse advocates for cancer patients, organ transplants and high-risk maternity.