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Members
Frequently
Asked Questions
Why
is WINhealth Partners better than other health plans?
The plan sounds expensive. Can I afford this?
Is
WINhealth Partners an HMO?
Do
WINhealth Partner physicians see patients who are in other
health plans?
Must
I get permission from the health plan to receive the medical
services I need?
Will I be covered when I'm out of town?
What do I do in an emergency?
What
if I need special medical care that isn't offered through
the network?
What about pre-existing medical conditions?
How much paperwork am I responsible for?
How
do I enroll? If I don't choose a WINhealth Partners plan
now, can I choose it later?
What
if my family status changes?
Why
should I switch to WINhealth Partners?
Does
low cost mean limited coverage?
What
exactly is being managed in a managed care environment?
The employer? The patients? The physicians?
What is the infrastructure of WINhealth Partners?
Why
is WINhealth Partners better than other health plans?
The majority of your area physicians and the local hospital
participate in our health plan. This level of involvement
among local providers makes WINhealth Partners a plan that
truly represents the needs of your community.
When
designing WINhealth Partners, our providers placed member
satisfaction first. That's why you can choose your own doctor,
and why we pay in full for preventive care office visits
that keep you at your healthiest. We want to detect and
treat small problems before they turn into big ones!
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Sounds
expensive. Can I afford this?
Believe it or not, our health plan costs far less than most.
There's no deductible*…just a reasonable fixed amount
(a co-payment) for routine care, emergency or urgent care,
or hospitalization.
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Is
WINhealth Partners an HMO?
WINhealth Partners is the only Health Maintenance Organization
(HMO) licensed in Wyoming, and as such, our emphasis is
on wellness.
We
have an open access system, meaning our members can select
their own doctor from among any of the participating physicians
in Wyoming. Our healthplan relies on the dynamic relationship
of members, providers, and employers working together to
balance the need for medical services with appropriate,
high-quality treatment options. We do require that members
stay in network, except in emergency situations or if they
are referred for services we cannot provide locally.
Our
HMO POS (Point-Of-Service) option allows members to see
any healthcare provider nationwide, as long as the service
is a covered benefit under the plan. The only difference
is that a deductible and coinsurance amount must be satisfied
for out-of-network services before we reimburse fees.
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Do
WINhealth Partner physicians see patients who are in other
health plans?
WINhealth Partners does not require the exclusive participation
of its physicians. Many of our participating physicians
work with other healthcare plans and insurance companies
as they deem necessary.
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Must
I get permission from the health plan to receive the medical
services I need?
Preauthorization is not required for routine office visits
due to illness or injury. However, preauthorization is necessary
for a scheduled hospitalization or surgery.
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Will
I be covered when I'm out of town?
When members are temporarily out of their local service
area, their emergencies and urgent illnesses are covered.
We only ask that members contact WINhealth Partners prior
to obtaining urgent (non-emergency) services.
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What
do I do in an emergency?
If emergency care is needed, you should go to the nearest
medical facility. Coverage for emergency care is available
7 days a week, 24 hours a day. Once the situation is stabilized,
you must receive follow-up care within the service area
from a participating provider.
An emergency is defined as a sudden onset of acute symptoms
that may result in serious jeopardy to your health if you
do not get immediate care. Some examples are chest pain,
difficulty in breathing and uncontrolled bleeding.
Sometimes a situation is not an emergency, but you need
same-day or next-day care. This is referred to as urgent
care. If a Member needs urgent care and is in the service
area, you should contact your personal physician and follow
his or her instructions.
If you are outside the service area and need urgent care,
you should contact WINhealth Partners to advise us of the
situation and then go to the nearest available doctor's
office or urgent care facility.
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What
if I need special medical care that isn't offered through
the network?
With virtually every major medical specialty represented
on our preferred provider list, it is likely that you'll
find everything you need in your own community. However,
if one of our physicians needs to refer you to an out-of-network
provider for services that aren't provided locally, those
charges will be considered in-network and will be fully
covered.
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What
about pre-existing medical conditions?
If you have had continuous coverage under a qualifying individual,
group, or government-sponsored health plan to a date not
more than 90 days prior to your effective date under a WINhealth
Partners plan and have satisfied the pre-existing waiting
period for your condition under your former plan, there
is no waiting period under our plan.
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How
much paperwork am I responsible for?
Great news! There is almost no paperwork. As long as you
make your co-payment at the time of service, there are no
bills from the physician, and there are never any claim
forms to submit. Just remember to carry your member identification
card in your wallet so you can identify yourself as a WINhealth
Partners member whenever medical services are rendered.
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How
do I enroll? If I don't choose a WINhealth Partners plan
now, can I choose it later?
Our health plans are currently offered to employer groups
with two or more employees. Employers can choose to participate
at any time. After an employer signs on with WINhealth Partners,
eligible employees must enroll within 30 days, or wait until
the next open enrollment period.
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What
if my family status changes?
Just notify your employer, who will contact us to arrange
the coverage you need. We will then send you an updated
membership card.
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Why
should I switch to WINhealth Partners?
Because it's easier on your company's bottom line! With
WINhealth Partners, you simply pay a low monthly premium,
and your employees enjoy the benefits of a comprehensive
health plan that significantly reduces their out-of-pocket
expenditures while keeping them healthier, and more productive
on the job!
With
your local hospital and the majority of your area doctors
on our preferred provider list, your employees will enjoy
almost unlimited choice in selecting the provider who's
right for them. They'll also appreciate the fact that there's
no deductible* in most plans, just a fixed amount (a co-payment)
every time they see their doctor. It's easy on your overhead
and easy on your employees' checkbooks…a winning proposition
for both of you!
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Does
low cost mean limited coverage?
Not at all! In fact, our health plan differs from most plans
in providing generous coverage for preventive as well as
corrective healthcare. Well-baby care, immunizations, routine
check-ups, and mammography are covered because we believe
regular check ups help prevent little problems from turning
into big ones.
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What
exactly is being managed in a managed care environment?
The employer? The patients? The physicians?
In a managed care environment, the processes of care are
managed in an attempt to seek cost-effective approaches
to preventive and curative care. In a fragmented, indemnity
environment, there is no attempt, nor would it be possible,
to bring process into healthcare purchasing or treatment
decisions. In a managed environment, the providers and the
health data of its members function within the same system,
allowing continual process management and improvement. An
accountable managed plan is continually searching for best
practice patterns and establishing performance benchmarks
based on its own standards, as well as nationally published
benchmarks for each process of care. In a managed environment,
the process managers are not only the providers, but also
the employer and members to the extent they are empowered
by the health plan to have input regarding the management
of their group.
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What
is the infrastructure of WINhealth Partners?
WINhealth Partners is nonprofit and is capitalized and self-governed
by its participating hospitals and physicians. As such,
the health plan does not have to focus on the need to generate
dividends for out-of-state investors; rather, its sole motive
is to improve the health status of the population in Wyoming
and retain the high quality of the medical infrastructure
currently operating in the region.
Medical
and operational decision-making is done at the local level,
meaning protocols are not developed by a distant, corporate
third party but by providers who understand the health needs
of the community.
WINhealth Partners offers two highly efficient managed plans:
an HMO (Health Maintenance Organization), and an HMO POS
(Point-Of-Service). Our HMO is an open-access system, meaning
its members can select their own doctor from among our participating
physicians. Traditional HMOs require the selection of a
primary care physician who serves as a "gatekeeper"
for treatment options, including the need for specialty
care. Unlike this gatekeeper model, our system relies on
the dynamic relationship of members, providers, and employers
working together to balance the need for medical services
with appropriate, high-quality treatment options. Our HMO
option requires that members stay in network unless they
are preauthorized for services we cannot provide locally.
Our HMO POS option allows members to seek medical care anywhere
in the nation, as long as the service is a covered benefit
under the plan.
WINhealth
Partners' emphasis is on wellness as the best approach to
controlling costs. Our plan design and the orientation of
our medical practices will emphasize preventive services
to avoid the cost of catastrophic illness.
The Employer
Due to the increasing cost of providing healthcare, employers
are now treating this expenditure more as an investment
than simply the cost of doing business. As such, they expect
to be informed about the status of their investment and
what's being done to manage their investment wisely. WINhealth
Partners intends to be in a dynamic relationship with its
employers to provide consultative and reporting services
so proactive solutions can be implemented for the employer's
specific population. It is our belief that a healthier population
will yield a greater return to the employer in terms of
overall productivity.
The Member
Member dissatisfaction with health plans that prohibit them
from selecting their own physician is well documented. Because
WINhealth Partners believes strongly in the value of the
traditional physician/patient relationship, its open-access
system allows members to select their own doctor. Because
the majority of local physicians are participants in our
network, members will have almost unlimited choice in choosing
their physician. WINhealth Partners believes that a long-term,
collaborative relationship between a patient and their physician
greatly enhances the process of preventive and appropriate
curative care.
The Providers
The commitment of the WINhealth Partner providers is shown
by their capital contribution to self-finance the health
plan and share the financial risk for the health of its
members. Not only will they provide patient care, but they
will also participate in governing the health plan as members
of internal committees concerned with such issues as care
pathways, access, utilization management, quality improvement,
and provider credentialing.
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