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Frequently Asked Questions

Scripps Health Plan (HMO)

Why did Scripps create the Scripps Health Plan HMO?

As part of our strategy to deliver excellent patient care at a lower cost, Scripps received approval from the State of California to develop an HMO insurance health plan. Scripps employees have the opportunity to be the first customers of the Scripps Health Plan HMO; a historic moment in our organizations’ history.
The Scripps Health Plan HMO for employees is managed internally by Scripps Health Plan Services, in partnership with Scripps benefits plan administrators. This new health plan is a model of what will be offered to the community starting in 2017 as part of our strategy to grow the business and increase our market share in San Diego County.
We can keep the HMO health plan costs low since all care is managed by Scripps and referrals are managed by your primary care physician and medical group. The employee HMO plan is only offered to those who can obtain all routine medical care within San Diego County.

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What is the Scripps Health Plan HMO?

Scripps Health Plan Services created and licensed a new HMO plan that was made available to employees and eligible dependents in 2016. The HMO plan offers a wide range of health care services through a network of Scripps providers who agree to supply services to members on a prepaid basis. Primary Care Physicians (PCPs) and their Plan Medical Groups (PMGs) coordinate and assume responsibility for your care. HMO plans are regulated by the Department of Managed Healthcare who monitor care, compliance, and financial solvency of California managed care plans.

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Do I need to select a Primary Care Physician (PCP)?

Yes, each covered member enrolled in the HMO plan must select a PCP at the time of enrollment. The selected PCP is responsible for coordinating all of your care, including referrals to specialists.

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Do I need to select a Plan Medical Group (PMG)?

PCPs have at least one medical group or PMG affiliation, but some can have multiple affiliations. It is important to review your PCP’s medical group affiliations and choose the correct medical group associated with your PCP. The correct medical group for you will include the specialists and facilities that you prefer to use. Your PCP will coordinate all of your care within their affiliated Plan Medical Group (PMG).

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What Plan Medical Groups (PMGs) participate in the Scripps Health Plan HMO?

There are six participating PMG:
  • Mercy Physicians Medical Group (MPMG)
  • Primary Care Associates Medical Group (PCAMG)
  • Rady Children's Health Network (RCHN)
  • Scripps Clinic Medical Group (SCMG)
  • Scripps Coastal Medical Center (SCMC)
  • Scripps Physicians Medical Group (SPMG)

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What are the advantages of selecting the HMO plan?

  • Lower premiums and out-of-pocket costs for services
  • Care coordination
  • Focus on Preventive care
  • Quality Care Metrics

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What are the main differences between the new HMO and the current EPO plan?

The main differences include:
  • Premium rates for the Scripps Health Plan HMO are lower than the EPO plan. For example, the HMO plan will cost between $19.63 and $45.55 less per pay period for full time employees depending on coverage category, subsidy level and wellness incentive.
  • The HMO requires you to select a PCP and PMG, and that PCP will coordinate all of your care within the PMG. The EPO plan requires a PCP selection for the lowest copay, but you can access care from any Scripps Custom Network provider and you are not restricted to a PMG.
  • The HMO plan offers Chiropractic/Acupuncture care through the American Specialty Health Plans of California Network. The EPO plan offers Chiropractic/Acupuncture care through the Anthem Blue Cross Network.
  • The HMO plan does not include coverage for out-of-area services unless urgent or emergent. Out of-area care may be covered if the member receives prior authorization for services not performed within the network.

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Can my son or daughter away at college be a covered dependent under the Scripps Health Plan HMO?

The Scripps Health Plan HMO will only cover urgent and emergent medical care received out of the San Diego County service area. If members receive routine, specialty, and/or elective services outside of their medical group and/or outside of the San Diego County service area, the services will not be covered. The member will be responsible for the full billed charges. Doctors On Demand online video consultations are available with 24/7 access to board certified physicians and licensed psychologists for a $15 copay. All routine care (office visits, specialist visits, annual screenings, etc.) will need to be coordinated by the PCP.

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Can I change my PCP and/or PMG after my original selection?

Yes, you may select a new PCP or PMG at any time. Your PCP change will be effective the first of the following month the date of your requested change. Each covered member may select a different PCP and/or PMG. Scripps Health Plan Customer Service is available to assist with making these changes or locating a new PCP. To make a PCP and/or PMG change, please contact Customer Service directly at (844) 337-3700 or via email at customerservice@scrippshealth.org. They are available to assist you Monday through Friday from 8 a.m. to 5 p.m. PST.

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With the Scripps Health Plan HMO, do I need to get a referral to see a specialist?

Yes, in most cases you do. You will have direct access to certain services such as annual mammogram screenings, OBGYN care within your PMG, and other routine services that may not require a referral. A member is allowed to self-refer to an OB/GYN who is not the assigned PCP, if the OB/GYN is part of the same medical group as the assigned PCP. Members are able to self-refer to providers that are part of the American Specialty Health Plan network for chiropractic and acupuncture services. Members are able to self-refer to providers that are part of the Cigna Behavioral Health (CBH) network for behavioral health and substance abuse disorder services.

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With the Scripps Health Plan HMO, can I get my health care from any doctor, other health care provider or hospital?

In the Scripps Health Plan HMO your care must be coordinated by your PCP and with the PCP’s affiliated Plan Medical Group (PMG). The Scripps Health Plan HMO has a robust network with thousands of participating physicians, the Scripps Network of hospitals, and an extensive network for pharmacy, mental health services, and other ancillary providers.

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Are prescription drugs covered in the Scripps Health Plan HMO?

Yes, prescription drug benefits are covered on the HMO plan. The pharmacy benefit is outlined in the Evidence of Coverage (EOC) document which details the plan design and can be found in the Medical Plan Documents section on the left side of the page.

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Can my child continue to see their Rady’s pediatrician?

Effective January 1, 2017, Rady Children’s Health Network (RCHN) is a contracted PMG for pediatric primary care. These physicians are available for PCP effective dates of January 1, 2017 and forward.

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Is there coverage for Mental Health and Chemical Dependency under the Scripps Health Plan HMO?

Yes, mental health and chemical dependency services are covered under the HMO Plan through Cigna Behavioral Health (CBH). Members have direct access for behavioral health and substance abuse disorder services. Members can self-refer to ANY contracted CBH provider and the provider does NOT have to be affiliated with the member’s elected medical group. The CBH network is a national network, so any in-network provider, regardless of location, is in-network for any member, regardless of where he/she resides. This applies for any covered member including dependents who live outside of the San Diego County service area. . To see if your current provider is available, visit their website at www.cignabehavioral.com, under “Member” click on “Find a Therapist/Psychiatrist” or call 800-866-6534 to speak to a Cigna Behavioral Health representative.

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What else do I need to know about the Scripps Health Plan HMO?

If your doctor or other health care provider leaves the plan, SHP will notify the affected members, and provide direction of how treatment going forward will be handled so there is no disruption to your care. You may contact the Customer Service Department at 844-337-3700 to receive a list of providers for ongoing care and to assist with any additional questions. Our Case Management and Utilization Management teams will work with the PMG, provider(s) and/or the member if special needs or circumstances require a Continuity of Care plan.
If you get unauthorized health care outside of your PMG, the services will not be covered and you will be responsible for the full billed charges.

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What do I need to do to elect the Scripps Health Plan HMO?

These simple steps will get you enrolled:
  • Choose a Primary Care Physician (PCP) for yourself and each of your family members. A PCP coordinates your health care, maintains your medical records, provides routine care and refers you to specialists and other services as medically necessary.
    • Visit www.scrippshealthplan.com to search for a provider.
    • Select the 'Find a Doctor' option at the top of the page
    • You may filter your search by Plan Medical Group (PMG), provider name, and provider type, and further refine the search by other identifiers such as gender, language, and office location.
    • Some things to keep in mind:
      • Make sure the PCP you select is part of the PMG you want.
      • Some PCPs are available in more than one PMG.
      • You may choose a different PCP and PMG for each family member.
      • If you do not already have a PCP, or if your current PCP isn’t listed, there are thousands of quality physicians participating with the Scripps Health HMO Plan to choose from.
      • Review the specialty care, ancillary providers and affiliated hospital associated with the PCP and PMG you select to ensure access to the preferred providers and facilities you want.
Schedule a doctor’s appointment. Get to know your PCP by scheduling an annual physical. It’s a good time to discuss your health history, including any prescription or over-the-counter medications you take. If you have an established relationship with your PCP already, you should still make an appointment to ensure you have taken all steps to stay healthy. They will check your vital signs, go over your medications and schedule you for preventive care screenings (i.e. pap smears, colonoscopies, vaccines, etc.).

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