Member Handbook
GOVERNMENT OF GUAM
For Contract Period FY 2016-2017
www.netcarelifeandhealth.com
Hafa Adai GovGuam Employee,
Retirees & Survivors...
Welcome and thank you for choosing NetCare! Your health and wellness play an important role in your everyday
life, and we know how important it is to be able to receive quality and timely medical care, no matter when or where
you need it.
We are committed to providing our members and their families with the highest level of service possible and hope
that the information included in this handbook will assist you in understanding your NetCare benefits and services.
Please take a moment to review this information and then keep this handbook together with your enrollment guide
in a safe place for future reference. The Open Enrollment Guide together with the Member Handbook provides
detail information and important plan features. In addition, it gives you tips on how to receive the highest level of
health care benefits. However, neither handbook is a contract. A detailed description of specific terms, as well as
the conditions and limitations of your coverage are outlined in the Group Health Insurance Agreement executed
between NetCare and the Government of Guam.
You may also view this handbook on line at www.netcarelifeandhealth.com
under the GovGuam Member Portal page.
GOVGUAM | 1
About NetCare
What’s New for FY2017
NetCare Life & Health Insurance Company is owned and administered by Moylan’s Insurance Underwriters, Inc., a locally based
multi-line insurance agency with over 45 years of insurance benefits
experience on Guam, CNMI and throughout Micronesia.
NetCare covers members on Guam, CNMI, Palau, Federated
States of Micronesia and the Republic of the Marshall Islands.
NetCare products are reinsured by RGA Reinsurance Group, one
of the largest reinsurance companies worldwide.
•
Hyperbaric Oxygen Therapy and Wound Care Treatment
•
Clinical Trials Coverage
•
New Fitness Rewards up to $360
•
Travel Allowance up to $500
•
Free Guam Running Club Membership
•
Vision hardware not applied to deductible under PPO 1500
Plan
We are pleased to be offered to Government of Guam employees
and retirees are delighted to welcome you to NetCare. We provide
you with access to quality care and services and look forward to
serving you.
Contact Us – Customer Service Center
NetCare’s Customer Service Representative are trained to respond and answer your question and to assist you in
using your plan properly and efficiently. Our Customer Service Center is located at the Julale Center in Hagatna and
is available Monday through Friday, 8:00am to 5:00pm and on Saturday from 9:00am to 1:00pm. We can assist
you with:
• Locating a health care provider
• Answering questions about claims, deductible, benefits and coverage
• Coordinating reimbursement
• Arranging for an off-island medical referral
• Member Identification Cards
Address
-
424 West O’Brien Drive Suite 200, Hagatna, Guam 96910
Phone
-
Direct - 1-671-475-7337
-
Toll Free (while in the U.S.) 1-888-966-9526
Facsimile
-
1(671) 477-5672
Nurseline 24/7
-
1-877-585-5376
Global Emergency
-
1-877-330-3681
Assistance 24/7
-
Collect Call 1-905-532-3732
E-mail
-
[email protected]
Website
-
www.netcarelifeandhealth.com
GOVGUAM | 2
USING YOUR NETCARE PLAN
Residency Requirement / Service Area
Enrollment with NetCare is limited to only those members who live
on Guam and do not reside outside of Guam for more than one
hundred eighty two (182) consecutive days per Contract Period.
Dependent Children who reside off-island are eligible to enroll under
the plan and shall not be denied coverage up to the attainment
age of 26 years.
For members who live on Guam and spent time receiving continuous medical care off-island, as approved and authorized by
NetCare, that is not for long term maintenance treatment, shall not
count toward the one hundred eighty two (182) days maximum
provided the receipt of such care precludes the member from
returning to Guam. These cases will be subject to medical case
review to determine the necessity of out-of-area extended stay as
well as authorization for continuation of medical care by NetCare.
In addition, time spent by a parent or spouse of a member shall
not count toward the one hundred eighty two (182) day maximum,
provided the parent or spouse is providing necessary assistance
to the Covered Member . However, under no circumstances can
there be more than one such caregiver for any incident of care out
of the service area.
Member Identification Cards
Upon enrollment with NetCare, you will receive your NetCare membership card for you and each covered dependent. Check your
card to make sure that the information printed is accurate and
correct. If you need to make changes, please contact our Customer
Service Center.
Your NetCare membership card identifies you as a NetCare member
and gives you access to medical services. Always carry your membership card with you and present it whenever you receive health
care services. This will
help ensure that your
claims are processed
properly.
If you lose your card, you
can contact our Customer Service Center to
request a replacement
card and a new card will
be sent to you immediately. You can also print a temporary membership card by logging in to MyNetCare member portal at www.
netcarelifeandhealth.com or download MyNetCare Mobile App and
instantly receive your ID card on your smart phone.
HIPAA (Health Insurance Portability and Accountability Act of 1996)
Under HIPAA provisions, employees and eligible dependents may
enroll outside of their eligibility period within 30 days if any of the
following qualifying events have occurred:
• Loss of other coverage (as a result of involuntary termination of
employment, divorce, legal separation, death or reduction in hours).
• Legal Marriage
• Birth of a baby
• Adoption or placement for adoption
Should an employee or dependent qualify for a special enrollment period under
HIPAA, the individual must request special enrollment within 30 days of marriage,
birth, adoption, placement for adoption or
involuntary loss of other health coverage.
In the case of marriage, birth, adoption
or placement for adoption, enrollment is
required to be effective not later than that
first day of the first calendar month beginning after the date the completed request
for enrollment is received and approved
by the Plan. (Legal guardianship is not recognized under HIPAA
provisions).
Leave Without Pay Status
As an employee, you will be responsible for paying both the government and employee’s share of the medical and dental premiums (whichever is applicable) while on leave without pay status.
All payments must be made to NetCare Life & Health Insurance
Company at our administrative offices in Hagatna. Initial premium
payment must be made within thirty (30) days of the start of Leave
Without Pay status. Subsequent premium payments must be
made by the 15th of each month prior to the month of coverage.
Premium payments that are not paid on a timely basis will result
in a termination of coverage and employee will not be allowed to
enroll in the plan until the next Open Enrollment Period.
For those employees on active duty military leave status and wish
to continue enrollment with NetCare during such leave period
will be required to provide a copy of their military orders to NetCare. Employees are advised to contact their Human Resources
Division for premium payment information. Upon completion of
military orders or leave status, the employee may re-enroll with
NetCare by contacting their respective department or agency
GOVGUAM | 3
Human Resources Office.
Incomplete claims or reimbursement form will be returned to the
member. Claim reimbursement that is filed beyond 120 days of
the date of service will be denied and become the sole financial
responsibility of the member. NetCare will reimburse members
based on the Plan benefits within 30 to 45 days of receipt of all
completed and required documents
Termination of Coverage
Your coverage as an Enrollee will end on the following
occurrences:
• If premiums are not paid, or
• If you allow someone else to use your member identification card
to obtain services, or
• If you remain outside of the service area for more than 182 consecutive days, except for time receiving continuous medical care
off-island, that is not for long term maintenance treatment, shall
not count towards the 182 day maximum provided the receipt of
such care precludes returning to Guam, or
• A spouse’s coverage will end on the first
day of the month following the termination of
your marriage. A cohabitate partner’s coverage will end on the first day of the month following the date the couple is no longer living
or residing together. You must complete and
submit all necessary forms in these events.
How to file a Claim or Seek
Reimbursement
Participating providers will file claims on
your behalf. If the physician/facility is a
non-participating provider (outside of our
network), you may be required to make payment at the time of
service and then file a claim reimbursement with NetCare. You must
file the claim at our Customer Service Center within 120 days of the
date of service with all of the following information or documents:
• Completed/Signed request for Reimbursement Form for each
provider.
• Original Receipts and/or copies of credit card statements or cancelled checks
Other Insurance
When you or your dependents have additional coverage under
another health plan or insurance program (for example, a plan
through your spouse’s employer or Medicare) coordination of benefits (COB) may apply. COB eliminates duplicate payments for the
same expense and plays an important role in controlling the price
you pay for your health care coverage.
While it is important that you receive the health benefits for which
you are eligible, it is just as important that payments are properly
coordinated so that one health insurance carrier does not exceed
its payment responsibility for your bill. The combined payment by
NetCare and the other insurance plan should not be more than
the total amount of the bill.
We update our COB information periodically. Therefore, it is important to let us know if you have other insurance coverage and/or if
your other insurance coverage has changed. You can contact our
customer service center at 475-7337 to supply this information.
HEALTH AND QUALITY OF CARE
Pre-Certification Review
In order to ensure that our members are receiving the highest
standard of health care, in the most appropriate setting, and in
the best interest of the member, the plan requires pre-certification
for the following services:
• Inpatient confinements
• Insurance Claim form completed by the provider for each date of
services.
• Outpatient Elective Surgery
Medical notes are required for all services rendered in the Philippines, including prescription drugs and dental claims. Reimbursements that are submitted for emergency care for services rendered
in Asia must include detailed medical notes and receipts translated
into English (including prescription drugs and dental claims).
• Durable Medical Equipment
Prescription Drug reimbursements must include the exact medication dispensed and the exact dosage. (Medical notes may be
required). Reimbursement request for dental services must also
include a claim form. Reimbursement requests for services rendered
in the Philippines must include a Tooth chart. Please note that
NetCare does not accept cash register receipts for reimbursement.
• Home Health Care
• Major Diagnostic Procedures such as MRI, CT Scan, and Ultrasound
on an outpatient basis.
Pre-certification will require the medical provider to notify NetCare
before any procedure, either hospitalization or surgical is rendered.
Notification allows the plan to authorize payment and to recommend
alternate courses of action if necessary.
Disease Management and Wellness
NetCare offers a variety of disease and wellness programs designed
with your better health in mind. We include a wide range of wellness
GOVGUAM | 4
and health improvement benefits including preventive physical
examinations, test to identify health risks, health screenings to
detect cancer and other conditions while they are still curable.
NetCare has contracted with the following wellness providers to
facilitate and provide a range of wellness and health improvement
programs and activities for members:
• SDA Wellness Center
macy closest to you in Hawaii or the Continental U.S., please call
the Optum Rx toll-free number 1-877-559-2955. The pharmacy
will need the numbers listed on the front and back of your member
identification card to process your prescription electronically. For
additional information, members may visit the Optum Rx website:
www.optumrx.com.
Specialty Drugs are limited and dispensed at Kmart Pharmacy on
Guam and Hawaii only unless prior authorized by NetCare. Specialty drugs dispensed in the U.S. Mainland are limited to Kmart
Pharmacy and Optum Rx Specialty Pharmacies.
• Health Services of the Pacific
• Dr. Horinuchi Wellness Clinic
• Dr. Lombard’s Weight Management Program
• Lohas Chiropractor and Nutrition Clinic
Your covered benefits also include educational and treatment
programs for risk factors or conditions such as diabetes, asthma
management, hypertension, pre-natal, neonatal, smoking cessation
etc… that may lead to serious but avoidable complications. We urge
you to take advantage of these benefits. They will help you improve
your health, stay healthy and lead a better and longer lifestyle.
You may also log onto our website at www.netcarelifeandhealth.
com and click on the Health and Wellness page for more detailed
information and resources.
Prescription Drug Benefits
NetCare has contracted with Optum Rx Solutions to administer
our pharmacy benefits. Prescription coverage is limited to generic
brands only, unless a brand name drug is specified in writing by
an attending physician, and unless there is no generic substitute
available. If a brand name drug is requested and a generic substitute
is available, the member will be charged the difference in cost for
the brand name drug (which may vary month-to-month) in addition
to the applicable prescription drug co-payment. NetCare has implemented a Prescription Formulary Guideline to serve as a guide in the
selection of cost effective drug therapy. Although NetCare has an
open formulary, we do encourage all participating providers
to adhere to the formulary. You
can view the Drug Formulary at
www.netcarelifeandhealth.com
under the GovGuam of Guam Member Portal.
At times, a Prior Authorization (PA) may be required before prescription drugs are dispensed. In this case, the pharmacy will communicate with Optum Rx for approval. Prescription drugs dispensed
by nonparticipating pharmacies (pharmacies not contracted with
Optum Rx are not covered under the plan).
NetCare members have access to 65,000 pharmacies in Guam,
Saipan, Hawaii and the Continental U.S. through the Optum Rx
Pharmacy Network. Regular prescription drug co-payments will
apply when accessing participating pharmacies. To locate a phar-
NetCare members may order a three-month supply of their maintenance prescriptions through the mail order program with reduced
co-payments. You may request a Mail Order Form from NetCare’s
Customer Service Center at the Julale Center, or by logging onto
the Optum Rx website at www.optumrx.com.
In addition, members are encouraged to take advantage of the
various pharmacy cost-savings programs available such as the
Hassle Free Re-fill Program; Brands for Generic Program; Retail
90 Rx Program; OTC Program; and the Half-Tab Rx Program.
Specialty Drugs dispensed are limited to Kmart Pharmacy only
on Guam and Hawaii. Specialty Drugs dispensed in the U.S.
Mainland are limited to any Optum Rx Specialty Pharmacies
including Kmart Pharmacies.
Preventive Care and Screening
NetCare places great importance on
preventive care, and encourages
all members to have their annual
physical exams and screening.
Preventive Care includes the
following:
• Annual outpatient physical
exams include the following
health screenings (age appropriate).
• Screening for high blood
pressure and high blood
cholesterol and other
lipid abnormalities for
men ages 35-65 and
women ages 45-65.
• Prostate
cancer
screening: PSA
(Prostate specific antigen) for
males 50 years
and older.
GOVGUAM | 5
NETWORK AND
PHYSICIAN SERVICES
• Colorectal (Colon) Cancer Screening:
• Cervical Cancer Screening (Pap test)
• Vision screening
• Breast Cancer Screening: Mammography screening every 1-2
years for all women ages 40 years and above*
• Outpatient Labs;
• Prenatal Care;
• Well-Baby Care, up to age 4 years;
• Routine Immunizations, up to age 18 years.
NetCare strongly recommends yearly mammogram for women
starting at age 40 years. An authorization is required if the member
is under the age of 40 and if the member must have additional
mammograms within the limited periods.
e-Health On-line Tools and Solutions
With NetCare’s on-line resources, members have access to a world
of information and easy and powerful interactive web services that
provides access to personal benefit information and tools
designed to help you manage your health care coverage
– quickly, easily and at a time that’s convenient for you.
We encourage you to register at www.netcarelifeandhealth.com to access your secure online account. In
your secure online account, you will be able to:
• View 24-hour access to your paid claims and eligibility status
•
Confirm any needed referral and authorizations
•
Check and verify co-payment and co-insurance
amounts
•
View benefit coverage and plan deductibles, if any
and track how much you accumulated
•
View on and off-island provider listings
• Access to self–care medical and health information
regarding various medical conditions
•
Order and Print Member Identification
Card
• Review status of doctor and hospital bills
we have received for your care
•
Print and review Explanation of
Benefits (EOB)
Comprehensive Network of Participating
Providers
NetCare has contracted with a large and comprehensive network
of participating providers on Guam, CNMI, Micronesia, the Philippines, Asia, Hawaii, the Continental United States and Worldwide.
Please refer to NetCare’s Participating Provider Directory or visit
www.netcarelifeandhealth.
com to access the online
provider search directory.
You can feel confident you
can choose from over 1.6
million participating provider
facilities in our network, plus
the option to go outside the
network when you choose.
NetCare members have access to over 1.6 million provider facilities in the Continental United States and Worldwide through CMN
Global (dba) Europ Assistance. To find a participating provider, you
may call NetCare’s Customer Service Center at 475-7337 or log
in to www.netcarelifeandhealth.com and click on Provider Search
or you may contact Europ Assistance toll free at 1-877-330-3681
(available 24/7).
Off-island Medical Care and Referral
As a NetCare member, you are not required to get a referral to
access our Participating Providers. However, we encourage members to contact our off-island Care Coordinator so we may assist
you with arrangements for medical care off-island. By allowing us
to assist you, we can also verify provider status and benefit coverage. (It is important to note that when self-referring off-island, you
must ensure that the facility, attending physician, lab, etc. are all
in the provider network in order to avoid additional out-of-pocket
expenses). If you choose to go to a non-participating provider, all
services will be subject to plan deductibles and usual and reasonable charges.
Airfare Benefits to Centers of Care
NetCare provides a roundtrip economy airfare to specified Centers of Care facilities in the Philippines and California for members
meeting the following criteria:
• Has met or satisfied the annual deductible; prior to services being
rendered.
• Has NetCare as its primary insurance plan
GOVGUAM | 6
• Must obtain a written referral or pre-certification from a participating
physician and subsequent approval from NetCare.
• The referral must be for a procedure that is unavailable on Guam or
a criteria established and determined by NetCare. Some procedures
that may qualify for airfare benefit include but are not limited to:
Cardiac Catheterization, Cardiac Angioplasty, Open Heart Surgery,
Cancer Surgery, aneurysmectomy, intra cranial surgery, acute leukemia treatment, Neurosurgery and Gamma Knife Surgery.
NetCare’s Center of Care facilities include the following
in Asia including the Philippines with an approved pre-certification
from NetCare. Services are limited to medical procedures only for
inpatient and/or outpatient. Consultations, dental work, executive
checkups, annual physical exams, primary care visits or preventive
care visits are not eligible for the travel allowance benefit. The $500
Travel Allowance benefit is separate from the Airfare Benefit which
is primarily for a hospital to hospital transfer or for procedures not
available on Guam.
EMERGENCY AND
URGENT CARE
• Anaheim Regional Medical Center (Los Angeles, California)
• Good Samaritan Hospital (Los Angeles,California)
• The Doctors Medical Center (Modesto, California)
• KPC Healthcare (Orange County Global Medical Center, Anaheim
Global Medical Center, South Coast Global Medical Center, and
Chapman Global Medical Center) – (Los Angeles, California)
• Makati Medical Center (Manila, Philippines)
• St. Luke’s Medical Center (Manila, Philippines)
• The Medical City Medical Center (Manila, Philippines)
• Cardinal Santos Medical Center (Manila, Philippines)
Emergency Services
When you have a medical emergency, your health care coverage
is not the first thought that comes to mind. We encourage you to
become familiar with all the information in the handbook so you’ll
know how to get the maximum benefits available under your GovGuam group health policy if you should have a medical emergency.
If the situation is a medical emergency:
Round-trip airline tickets are direct flights from Guam to NetCare’s
Center of Care facilities, and are purchased at the lowest economy
fare available. An off-island referral does not guarantee airfare coverage as this is subject to approval and review by NetCare based
on plan policies and criteria. In the event the member purchases
an airline ticket in advance, NetCare will only reimburse no more
than what it would have paid had NetCare purchased the tickets for
the member in advance. Under no circumstances would NetCare
reimburse for any airline seat purchased with a frequent flyer miles
or similar mileage program. The cost of the airfare will be applied
to the member’s off-island plan maximum per contract period.
If the member is approved and qualified for airfare benefits by
NetCare and the service is one of the above mentioned specific
procedures or conditions, NetCare will provide for one airline seat
for a companion or family member of the Enrollee. In addition, if
it is medically necessary that a licensed medical attendant either
a physician, physician assistant, registered nurse or nurse practitioner accompany the member, NetCare will also provide for one
airline seat for such attendant for the same route as the member’s
route to and from the location of the attendant and the Center of
Care facility.
Travel Allowance
NetCare will reimburse members up to $500 that can be applied
towards an airfare and/or lodging expenses incurred. Annual
Deductible must first be satisfied under both the PPO 1500 and
the HSA 2000 Plans. The benefit applies to members that are
being referred for a medical procedures at a participating provider
• Call 911 or
• Go directly to the nearest hospital or emergency facility
Medically Necessary or Medical Necessity means the use of a
service or supply that is:
• Commonly and customarily recognized as appropriate in the
diagnosis and treatment of a member’s illness or injury;
• Appropriate with regard to standards of good medical practice;
• Not solely for the convenience of the member, his or her physician,
hospital, or other health care providers; and
• The most appropriate supply or level of service that can be safely
provided to the member.
Urgent Care
An “Urgent Condition” is a condition that is not a
threat to life or limb, but does require prompt
medical attention.
If the situation is urgent:
• Contact your physician. If your physician is unavailable or if you are unsure
about the meaning or seriousness of
the symptoms, you can call NetCare’s
24/7 Nurseline at 1-877-585-5376 for
immediate assistance and guidance; or
• Go directly to an urgent care center.
NetCare’s urgent care centers include
the following facilities:
GOVGUAM | 7
• SDA Clinic
• IHP medical Group
• American Medical Center
• HagatnaMed
• Urgent Care Clinic at the Guam Memorial Hospital.
Urgent Care Centers are walk-in medical facilities equipped to
handle minor medical emergencies. Most the clinics listed above
have evening and week-end hours should a medical condition
require immediate attention. Remember, urgent care centers do
not take the place of your physician. Your physician should be your
first contact whenever you need medical care.
MEMBER RIGHTS
AND PROBLEM
RESOLUTION
that this is a right we take very seriously. Your right to confidentiality
extends to all information that is unique to you. As a health insurance
company, we regard this to mean information that can be used to
identify you, such as your name, address, social security number,
and birth date along with data we have about the services you
have received or the premium you pay.
NetCare is committed to keeping the confidential information of
members private. Under HIPAA, the law gives you certain rights that
pertain to your Protected Health Information (PHI). As a NetCare
member, you have the right to:
• Request that we restrict the PHI we use or disclose about you for
payment or health care operations;
• Request that we communicate with you regarding your information
in an alternative manner or at an alternative location if you believe
that a disclosure of all or part of your PHI may endanger you.
• Inspect and copy your PHI that is contained in a designated record
set including your medical record;
Appeal and Grievance Procedures
The Affordable Care Act ensures your right to an internal appeal
or asks NetCare to reconsider its decision to deny payment for a
service or treatment. The law also permits you to have an independent review organization (an external review) decide whether
to uphold or overturn NetCare’s internal appeal decision.
NetCare uses guidelines from the Uniform Health Carrier
External Review Act to assure you have the opportunity
for an independent review of an adverse determination
or final adverse determination.
If a claim is denied, in whole or in part, NetCare will
furnish notice to you specifying the reason or describe
any additional information required in perfecting the
claim and your right to file an internal or external
appeal. If you wish to review and discuss the reason
for the denial, a request must be made in writing to
NetCare within one-hundred eighty (180) days
of receipt of a denial notice. NetCare will
re-evaluate the claim in question and give
a final written decision on the re-evaluation within sixty (60) days for services
already incurred, thirty (30) days for
non-urgent care not yet received, or
seventy-two (72) hours for urgent
care, after such request is received.
Privacy and Confidentiality
• Request that we amend your information if you believe that your
PHI is incorrect or incomplete;
• An accounting of certain disclosures of your PHI that are for reasons
other than treatment, payment, or health care operations; and
• Give us written authorization to use your protected health information
or disclose it to anyone not listed in the Notice of Privacy Practices.
We are required to send you a copy of our Notice of Privacy Practices. The notice outlines the uses and disclosures of protected
health information, the individual’s rights and NetCare’s responsibility
for protecting our member’s health information. You will receive
a copy of the Notice of Privacy Practices as part of our member
fulfillment packet upon enrollment.
If you have any questions concerning the confidentiality of your
personal information and data, please contact our Privacy Officer
at (671) 472-3610 extension 222.
HIPAA Portability
The Health Insurance Portability and Accountability Act of 1996
(HIPAA) ensures that individuals who have health insurance do not
experience a gap in coverage due to termination or departure from
their current job. A member terminating coverage with NetCare
will receive a Certificate of Creditable Coverage indicating the
length of time they have had health coverage. This Certificate of
Creditable Coverage is used to reduce any waiting time for pre-existing conditions that may be part of subsequent health insurance
coverage, as long as there has not been a break in coverage for
more than 63 days.
You retain the right to have all your personal
information and records safeguarded and
kept private and confidential as a NetCare
member. We at NetCare want to ensure you
GOVGUAM | 8
“Please Note: The information contained in this Member Handbook is only for general information and a Summary of NetCare’s plans offered to the Goverment of Guam, employees and retirees. Full details of benefits and
limitations are described in the Health Insurance Agreement and the Group Certificate issued between
NetCare Life & Health Insurance Company and the Government of Guam. In the event of a discrepancy
between this handbook and the Contract, the terms of the Contract will prevail. This Policy is underwritten by
NetCare Life & Health Insurance Company and is reinsured with RGA Reinsurance Company”
FY2016 - 2017