This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Health Plan of Nevada, Inc. holds the following accreditation: National Committee for Quality Assurance (NCQA). To learn more about this plan's accreditation, please visit the following website: www.ncqa.org. We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
General features of our High Option
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
When we contract with a doctor or medical group to provide health care services, the contract specifies the amount the doctor or medical group will be paid for providing services - either on a fixed monthly basis or as a payment per service provided.
We have several types of payment arrangements with our doctors:
- Arrangement A: Your doctor may be part of a contracted medical group and may receive a salary. Some medical groups may pay their doctors a bonus.
- Arrangement B: Your doctor may receive a fixed amount of money each month, called a "capitation," to provide services to all Plan patients they see. Capitation may be considered to be an incentive plan.
- Arrangement C: Your doctor may be paid a pre-determined amount for each service he/she provides.
Preventive care services
Preventive care services are generally covered with no cost sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including copayments, to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- HPN has operated as a mixed model HMO in Nevada for 40 years. HPN has been awarded an accreditation status of Accredited from the National Committee for Quality Assurance (NCQA), an independent, not-for-profit organization dedicated to measuring the quality of America's health care. Accreditation is for the Commercial HMO and Commercial POS product lines in Nevada.
- We understand the importance of getting your questions answered. Whether you need an answer to a benefit question, have a concern about a claim or need help in selecting a provider, we are available Monday through Friday, 8 a.m. to 5 p.m. at 877-545-7378.
- At times, services required on your behalf by your provider may not be approved by HPN. The decision to deny coverage for services requested, courses of treatment or inpatient care is made by a physician. These denials are based upon medical necessity, benefit coverage and your individual needs. Written notification of the denial will be sent to you, your primary care provider and the provider who requested the service. You have the right to appeal these decisions.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, Health Plan of Nevada at www.healthplanofnevada.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 877-545-7378, or write to Health Plan of Nevada, Inc., P.O. Box 15645, Las Vegas, NV 89114-5645. You may also visit our website at www.uhcfeds.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website Health Plan of Nevada at www.healthplanofnevada.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is: Clark, Esmeralda, and Nye counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.