COVA Care Frequently Asked Questions

MEDICAL SERVICES

Q.

How do I choose a primary care physician (PCP) or specialist?

You are not required to designate a PCP or obtain a referral to a specialist under COVA Care. You may visit any PCP or specialist in the Anthem network. A PCP is defined as a family or general practitioner, pediatrician, or internist. Select a PCP or specialist from the network using the Commonwealth of Virginia and The Local Choice Provider Directory. This directory is available from your Benefits Administrator, or you may view the directory at www.anthem.com. The directory on the Web site is updated continuously. 

You may also call Anthem Member Services at (804) 355-8506 in Richmond or 1-800-552-2682 outside Richmond to find out if a particular doctor participates in the Anthem network. You may want to confirm with the doctor's office that you will be accepted as a patient.

top of page

Q.

Even though COVA Care does not require that I designate a primary care physician (PCP), should I still have a primary doctor?

Yes. While you no longer must designate a PCP or obtain a referral to a specialist, it is a good idea to have a primary doctor who coordinates your care and knows your medical history. You must seek care from physicians and facilities that are in the Virginia provider network or participate in the Anthem BlueCard PPO network outside the state (see question 4).  Employees and family members will pay the $25 PCP copayment when seeking care from a physician in the provider network who is in general or family practice, pediatrics or internal medicine. The $35 specialist copayment appliesto office visits at any other in-network provider. Unless you have separate out-of-network coverage, you have no benefits under the basic plan when using a non-participating provider except for emergency care.

top of page

Q.

Does COVA Care pay for services outside Virginia?

The new plan includes the Anthem BlueCard PPO network, which allows you and your covered family members to use PPO network providers and facilities outside Virginia. To receive the highest level of benefits if you live or travel outside Virginia, you should receive care from providers who participate in a Blue Cross and Blue Shield company's BlueCard PPO network. Blue Cross Blue Shield PPO network providers who participate in the BlueCard PPO will accept your plan copayment or coinsurance instead of requiring full payment at the time of service. These providers or facilities will file your claim for you, and have agreed to accept the allowable charge established by their local Blue Cross and/or Blue Shield plan as payment in full for their services. If you go to a non-participating provider, the basic plan will pay for care only in an emergency. To find providers outside Virginia in the BlueCard PPO network, visit www.bcbs.com or call 1-800-810-BLUE (2583).

top of page

Q.

What is considered an emergency under the COVA Care plan?

An emergency is the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain that without immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in: 

• serious jeopardy to the mental or physical health of the individual;

• danger of serious impairment of the individual's body functions;

• serious dysfunction of any of the individual's bodily organs; or

• in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Action: Go to the nearest hospital or medical facility. Be sure to obtain Hospital Admission Review if admitted by calling Anthem at (804) 359-7277 in Richmond or 1-800-242-7277 outside Richmond.

top of page

Q.

What is medical necessity review?

In addition to the Hospital Admission Review process, the COVA Care plan requires that selected services be reviewed to determine if they are medically necessary. Some examples of these services include:  elective ambulance services; non-routine dental services; diabetic education; home care services (except home infusion therapy); medical equipment, devices, appliances and supplies; spinal manipulation in conjunction with physical therapy; morbid obesity treatment; non-routine oral surgery; organ and tissue transplants; and cardiac rehabilitation.

COVA Care recommends completing the medical necessity review process in advance of actually receiving services so that you will know beforehand whether or not the services meet the medical necessity criteria.  Services that do not meet the medical necessity criteria are not covered.  If you do not complete the medical necessity review process prior to receiving services, the review will be completed at the time the claim is processed.

For more information on medical necessity review, contact Anthem Member Services at (804) 355-8506 in Richmond, or 1-800-552-2682 outside Richmond.

top of page

What's included under COVA Care for preventive care?

COVA Care covers individuals age 7 and over and there is no deductible to pay before the plan pays for benefits. Coverage includes an annual gynecological exam or prostate exam (age 40 and older) at $25 per PCP visit or $35 per specialist visit. The plan pays 90% coinsurance for routine lab tests and x-rays at facilities and doctors offices, and the following services once per calendar year: a Pap test, mammography screening (one per year, age 35 and older), prostate specific antigen (PSA) test (age 40 and older) and colorectal cancer screening (age 40 and older).

top of page

Q.

What wellness coverage do members have under COVA Care?

Routine wellness care is covered for children through age 6 and for children and adults age 7 and over. There is no deductible for the member to pay before the plan pays for routine wellness coverage. Routine well child care through age 6 requires a $25 copayment per PCP visit and $35 copayment per specialist visit. Immunizations are covered at no cost. The plan pays 90% for routine lab tests and x-rays at facilities and doctors offices. Routine well adult care requires a $25 copayment per PCP visit and $35 copayment per specialist visit for a routine annual wellness check-up. The plan pays 90% coinsurance up to $200 per member per year for routine lab tests, immunizations and x-rays at facilities and doctors offices.

top of page

Q.

What diabetic supplies and equipment are covered under the COVA Care health plan?

A.

The COVA Care plan covers medical supplies, equipment and education for diabetes care for all diabetics. Coverage for the following is included under medical services:

• Insulin pumps;
• Home glucose blood monitors;
• Blood glucose test strips; and
• Outpatient self-management training and education performed in person; including medical nutrition therapy when provided by a certified, licensed or registered health care professional.

There is no charge for diabetic education. You pay 20% coinsurance for diabetic supplies and equipment after you have met your deductible, and the plan pays the remainder based on the allowable charge.

Please Note: Only insulin, syringes and lancets for diabetes care are covered under the COVA Care prescription drug program. The Three-Tier Drug Pocket Guide provided by Anthem with your plan identification card(s) contains general tier information on diabetes supplies that does not apply to the State Health Benefits Program. Please see the disclaimer in the brochure.

top of page

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Q.

Does COVA Care provide mental health and substance abuse benefits?

Yes. Magellan Behavioral Health administers mental health and substance abuse benefits. It is strongly recommended that COVA Care members obtain pre-authorization for mental health and substance abuse services. If an employee fails to obtain pre-authorization, but goes to a participating provider, Magellan will pay as long as the service is medically necessary. However, if pre-authorization is not obtained and care is sought at a non-participating provider, there will be no benefit.

top of page

ADDITIONAL COVERAGE OPTIONS

Q.

Does COVA Care provide dental coverage? If so, how does that differ from the coverage under Expanded Dental?

The COVA Care basic plan pays up to $1200 per member per calendar year for diagnostic, preventive and primary services. In addition to these, the Expanded Dental option provides complex restorative and orthodontic services. The annual benefit for Expanded Dental plus basic dental is $1500 per member ($300 more than for basic dental coverage). Expanded Dental also provides up to $1200 per member per lifetime for orthodontic coverage.

top of page

Q.

What is covered under the basic COVA Care plan with the Expanded Dental option?

The Expanded Dental option covers restorative and orthodontic services, with 50% coinsurance and no deductible.  The services are in addition to the basic COVA Care dental benefits.  Complex restorative dental services include inlays, onlays, crowns, dentures, bridges and implants.  The plan will pay up to $1,500 per member each year for the preventive, diagnostic, primary and complex restorative dental services under this option -- a $300 increase over the basic plan.  Orthodontic services are covered up to $1,200 per member per lifetime. The Expanded Dental option may be elected only  during the annual spring Health Benefits Open Enrollment period.

top of page

Q.

How does the COVA Care plan with the Out-of-Network option work?

The Out-of-Network option gives you access to providers who are not in the network, but the payment for covered services is generally reduced by 25 percent.  You are still responsible for any applicable deductible, copayment or coinsurance, and any balance above the allowable charge.  Payments for out-of-network claims are paid directly to you rather than to the provider.  The Out-of-Network option may be elected only during the annual spring Health Benefits Open Enrollment period.

top of page

Q.

I am enrolled in the basic COVA Care plan with the Vision, Hearing and Expanded Dental option. What coverage does the hearing benefit provide and is there a waiting period?

A.

There is no waiting period for hearing benefits under the Vision, Hearing and Expanded Dental option. Hearing coverage includes an exam from a hearing specialist ($35 specialist copayment) and $1200 per member every 48 months for hearing aids and hearing aid related services. The Vision, Hearing and Expanded Dental option may be elected only during the annual spring Health Benefits Open Enrollment period.

top of page

Q.

I currently have the COVA Care plan with the Vision, Hearing and Expanded Dental option. In February 2003, I had an eye exam and purchased new eyeglass frames under a previous statewide plan.  Will I have to wait another 24 months (until February 2005) for coverage?

Yes. Vision coverage under the new Vision, Hearing and Expanded Dental option provides a benefit every 24 months for an eye exam and lenses or eyeglass frames. You did not receive an additional 24 months when enrolling in the COVA Care plan with Vision, Hearing and Expanded Dental benefits.

top of page

DEDUCTIBLE AND OUT-OF-POCKET LIMIT

Q.

What applies to the annual deductible?

There is an annual deductible under COVA Care of $200 per person, up to a maximum of $400 per family. This is the amount you must pay for certain covered services before the plan will pay. The deductible applies to major medical, diagnostic tests and lab services. It does not apply to wellness, preventive, dental or drug benefits.

top of page

Q.

What counts toward the out-of-pocket limit?

The maximum amount you pay out-of-pocket under COVA Care is $1,500 per person, up to $3,000 per family. Expenses that count toward the out-of-pocket limit include your annual deductible, copayments and coinsurance. Additional information on the out-of-pocket limit is available in your COVA Care Member Handbook.

top of page

PRESCRIPTION DRUGS

Q.

What is the three-tier drug program?

Under the three-tier prescription drug program, drugs are divided into categories, or tiers, based primarily on cost. The first tier is typically generic drugs; the second tier is typically lower to middle-cost brand name drugs and some generics; and the third tier is typically higher cost brand name drugs. You pay for your drug based on the tier in which it falls.

top of page

Q.

Under the three-tier drug plan, can I purchase more than a 34-day supply of drugs at my local pharmacy?

Yes. Each 34-day supply requires a copayment. You may pay multiple network retail pharmacy copayments to purchase more than a 34-day supply. You may also purchase up to a 90-day drug supply at less cost, only twice your retail copayment, through the Home Delivery (mail service) pharmacy. Under the three-tier drug program, there is no longer a specific copayment for purchasing a 35-to-90 day supply at a retail pharmacy.

top of page

Q.

How can I determine in what tier my prescription drug falls?

To find out what drugs are in the three tier categories, visit the Anthem Web site and select the Prescription Drug Program link under the Commonwealth of Virginia and The Local Choice. You may also contact Anthem Member Services at 355-8506 in Richmond or 1-800-552-2682 outside Richmond.

top of page

Can I use the Home Delivery (Mail Order) Pharmacy for temperature-sensitive drugs? If so, how are the drugs protected during delivery?

Medco Health Home Delivery Pharmacy Service, which manages the Commonwealth's prescription drug mail order benefit, has developed special processes for the handling and shipping of some medications that are sensitive to temperature extremes. Medco Health has identified those medications that may lose potency when exposed to extreme temperatures. In Medco pharmacies, medications that are sensitive to heat are kept in refrigerated areas and when mailed, are placed in special insulated packages with gel packs designed to maintain the correct temperature. The packaging is designed to keep these prescriptions within the proper temperature range throughout the day of delivery. For medications that require a higher degree of special handling, Medco Health may also call you to arrange a convenient delivery time. For more information, visit the Medco Health Web site at www.medcohealth.com.

top of page

What is drug prior authorization?

Certain covered drugs can be dispensed only after the prescription is reviewed and approved. Your prescribing physician is aware of which drugs fall in this category and handles the prior authorization process for you.

If you are interested in knowing which drugs require prior authorization, the most current list is published on the Web at www.anthem.com. You may link to the list under Search the Drug Listing.

There are several reasons why a drug may require prior authorization, including:

• Patient safety - Some medications can be dangerous if prescribed or used incorrectly. While physicians are solely responsible for correctly prescribing medications, prior authorization is an additional step to help safeguard the health of members and ensure appropriate use of some medications.

• Limited uses -- Some drugs are FDA-approved for only a small number of situations. These drugs may be untested, dangerous or simply ineffective if used in ways not approved by the FDA. Prior authorization helps guard against the inappropriate use of these drugs.

• Price - Some drugs have an extraordinarily high cost. These drugs may require prior authorization to ensure that they are used only when necessary and only in appropriate amounts.

top of page

APPEALS

My claim has been denied and I don't agree with the decision. What should I do?

Start by discussing your problem with a Member Services representative to gain an understanding of why your claim was not paid. Contact Member Services at (804) 355-8506 in Richmond or 1-800-552-2682 outside Richmond. Should you decide further action is necessary, you may appeal the decision. The Member Services representative can help you start the appeal process. You must file your appeal within either 15 months of the date of service or 180 days from the date you were notified of the adverse benefit determination, whichever is later.

Appeals may  be sent to Anthem in writing or provided to an Anthem Member Services representative over the phone. Please include the following information:

• the patient's name, address and telephone number;

• your identification and group number (as shown on your identification card); and

• the name of the health care professional or facility that provided the service, including the date and description of the service provided and the charge.

If you disagree with Anthem's final decision and wish to appeal further, you may send your appeal in writing to the Director of the Department of Human Resource Management within 60 days of the decision. For more information about the appeal process, see your COVA Care Member Handbook.

top of page

OTHER INFORMATION

Where can I find a summary of benefits under COVA Care?

A summary of benefits begins on page 1 of your COVA Care Member Handbook.  There is also a copy of the summary under Compensation and Benefits on the DHRM Web site at www.dhrm.virginia.gov.

top of page

Who should I contact if I have questions about my plan benefits, or questions about eligibility?

If you have questions about your health plan benefits, such as what is covered and not covered, or the status of a claim, call Anthem Member Services at (804) 355-8506 in Richmond or 1-800-552-2682. Anthem Member Services is responsible for helping you with benefit and claims questions. Member Services cannot answer questions about eligibility.

If you have a question about eligibility, such as who you can enroll under your coverage, or qualifying mid-year events, contact your Benefits Administrator.

top of page

What is coordination of benefits?

Coordination of benefits applies only when you have coverage through other group health plans in addition to COVA Care. Since there is more than one plan, your benefits are coordinated between the plans.

You are required to notify Anthem that you are enrolled under another health plan(s). There are special rules that determine which plan will be responsible for the primary payment of claims. These rules are described in the COVA Care Member Handbook.

It is very important that you provide Anthem with complete information about any other health care coverage. This assures that your claims are paid correctly. If Anthem overpays benefits because it is discovered that you have other coverage, Anthem may recover the excess payment from you, the other insurance company, or any other organization as appropriate.

If you cover dependents under your plan, annually you will receive a postcard in the mail asking you to update information about the plans in which you are enrolled. Be sure to complete and return this card when you receive it. Claims will not be paid until you respond. Contact Anthem Member Services anytime you need to update information about your coverage under another plan. Call Anthem Member Services at (804) 355-8506 in Richmond or 1-800-552-2682 outside Richmond.

top of page

Q.

How does coordination of benefits work?

A.

When an individual has more than one health plan, the benefits are coordinated among the plans. One plan is designated to pay benefits first (or primary) and the other(s), when benefits are payable, to pay second (or secondary). Here are examples of how the COVA care coordination of benefits (COB) would work for dental and for orthopedic medical services.

Example 1: Dental Crown

The primary carrier (ABC Health Care Plan) has a $50 deductible and pays 50% coinsurance for services. COVA Care has no dental deductible and pays 50% coinsurance.

Example 2: Orthopedic Surgeon for Broken Ankle

The primary carrier (ABC Health Care Plan) requires the member to pay a $30 copayment for services. The secondary carrier (Anthem) requires a $35 copayment.

top of page

Q.

How do I know which carrier is primary for my health benefits?

A.

If you are a Commonwealth of Virginia employee participating in the COVA Care health plan, your primary carrier is Anthem. If your spouse is covering you under another health plan, his or her plan would be your secondary carrier. If you are the covered spouse of a State employee, and you are covered under your employer's plan, your employer's plan is the primary carrier and Anthem is secondary. For additional information on how primary and secondary coverage is determined for dependent children, see page 46 of the COVA Care Member Handbook.

top of page

Q.

When is it advantageous to have coverage under two separate health plans?

A.

There may be an advantage to coverage under two separate health plans if the secondary plan has a higher level of coverage or provides benefits not available under the primary health plan.

Example 1: Orthopedic Surgeon for Broken Ankle

The primary carrier (ABC Health Care Plan) requires the member to satisfy a $2,000 deductible before any claims are paid. The secondary carrier (Anthem) requires a $35 copayment.

Example 2: Dental Crown

The primary carrier (ABC Health Care Plan) does not provide coverage for crowns. The secondary carrier (Anthem) pays 50% coinsurance for crowns, not subject to a dental deductible.

top of page