Benefit Plans, Cost Sharing
and ID Cards
Geisinger Health Plan Fully Insured Commercial HMO
Geisinger Quality Options, Inc.
Geisinger Indemnity Insurance Company
Medicare Advantage (Geisinger Health Plan Gold)
Member Cost Sharing Information
Geisinger Health Plan Fully Insured Commercial HMO
Geisinger Health Plan offers fully insured commercial Health Maintenance Organization (HMO) coverage to employer groups and members. Coverage is in the form of a prepaid managed care gatekeeper product. Members are required to choose a Primary Care Physician (PCP) for themselves and each covered family dependent. Each member must obtain a referral for covered services not provided by the PCP, excluding emergency services and direct access services.
Members may be responsible for cost-sharing amounts in the form of copayments, deductible and/or coinsurance. Click here to access member cost-sharing information tools.
Fully insured commercial HMO products available under Geisinger Health Plan include:
• Geisinger Health Plan HMO
• Geisinger Health Plan HMO with Point of Service (POS) Rider
• Geisinger Health Plan Solutions
Mental health and substance abuse services for the above product lines are required to be coordinated through OptumHealth Behavioral Solutions at (888) 839-7972.
HMO Product Riders: Employer groups and non-group members have the option to purchase additional supplemental health services. The following list contains some of the riders available:
• Outpatient Prescription Drugs
• Durable Medical Equipment
• Prosthetic Devices
• Orthotic Devices
Any questions about a member’s eligibility, benefit coverage or the grievance and complaint procedures should be directed to:
HMO/Solutions Customer Service Team at (800) 447-4000 or (570) 271-8760, Monday through Friday, 8 a.m.-6 p.m.
TDD for the hearing impaired at (800) 447-2833, Monday through Friday, 8 p.m.-4:30 p.m.
Geisinger Quality Options, Inc.
Beginning March 1, 2007, Geisinger Quality Options, Inc., an affiliate of Geisinger Health Plan, will offer Geisinger Choice PPO with Referral, Geisinger Choice PPO with No Referral and Geisinger Choice PPO with No Referral High Deductible Health Plan (HDHP). These plans will take the place of the Selectus PPO plans described below. New PPO members will be enrolled in one of these three Choice plans. Current Selectus members will transition to Choice upon renewal of their benefit year, a process which will continue through April 2008.
• Geisinger Choice PPO with Referral (replaces Selectus Coordinated Care PPO) is the name for our gatekeeper PPO plan. It is a network-based fully insured managed health care program that offers coverage for in and out-of-network services. Members are required to choose a PCP upon enrollment. Members may elect to have health care services coordinated in network by their PCP to receive maximum benefit allowance. Or, health care services can be obtained from a participating or non-participating provider without PCP coordination at a lower benefit allowance. When a member elects to coordinate care through their PCP, the referral process and the precertification/prior authorization responsibilities of participating providers are applicable. Member may be responsible for copayments and/or deductibles and coinsurance. The terms and conditions of coverage for members enrolled in Geisinger Choice PPO with Referral are defined in the Geisinger Choice PPO with Referral Subscription Certificate.
• Geisinger Choice PPO with No Referral (replaces Selectus Direct Access PPO) is the name for our non-gatekeeper PPO plan. It is a network-based fully insured managed health care program that offers coverage for in and out-of-network services. Member do not select a PCP and may access care from either a participating or non-participating provider. The referral process is not applicable to Geisinger Choice PPO with No Referral Members. However, participating providers are responsible to request precertification/prior authorization for applicable services. Members may be responsible for copayments and/or deductibles and coinsurance. The terms and conditions of coverage for members enrolled in Geisinger Choice PPO with No Referral are defined in the Geisinger Choice PPO with No Referral Subscription Certificate.
• High Deductible Health Plan (HDHP): This plan is similar to the Geisinger Choice PPO with No Referral plan, and does not require members to select a primary care provider or obtain referrals. Prior authorization/precertification is required for some services. All covered health care expenses are applied to the member’s deductible, except for certain preventive tests and services, which are covered at no cost to the member. Because an HDHP member must first meet a deductible, providers should not collect any payment when services are rendered. A claim should be submitted to the Health Plan. The provider will then receive an explanation of payment (EOP) which will indicate the amount they should collect directly from the member. High Deductible Health Plan members will have identification cards imprinted with the Geisinger Choice logo and “High Deductible Health Plan” on the front of the card. There will be no benefit code on this card; instead, a note will appear to remind providers that deductibles apply to this plan. The back of the card will include a reminder that this plan is offered by Geisinger Quality Options, Inc., to avoid any confusion about the member’s insurance company.
Questions should be directed to:
Geisinger Choice PPO with Referral
M-F, 8 a.m.-6 p.m. (800) 447-4000, (570) 271-8760
Geisinger Choice PPO with No Referral and HDHP
M-F, 8 a.m.-5 p.m. (800) 504-0443, (570) 271-8770
TDD for the hearing impaired M-F, 8 a.m.-4:30 p.m. (800) 447-2833
Geisinger Indemnity Insurance Company
Geisinger Indemnity Insurance Company (Company), an affiliate of Geisinger Health Plan, offers a fully-insured direct access and coordinated care Preferred Provider Plan (PPO) and a comprehensive major medical group indemnity insurance plan. Company also acts as a Third Party Administrator (TPA) for employer-sponsored programs.
• Selectus Coordinated Care PPO: is the name for Company’s gatekeeper PPO plan. Selectus Coordinated Care PPO is a network-based fully insured managed health care program that offers coverage for in and out-of-network services. Members are required to choose a PCP upon enrollment. Members may elect to have health care services coordinated in network by their PCP to receive maximum benefit allowance. Or, health care services can be obtained from a participating or non-participating provider without PCP coordination at a lower benefit allowance. When a member elects to coordinate care through their PCP, the referral process and the precertification/prior authorization responsibilities of participating providers are applicable. Member may be responsible for copayments and/or deductibles and coinsurance. The terms and conditions of coverage for members enrolled in Selectus Coordinated Care PPO are defined in the Selectus Coordinated Care PPO Subscription Certificate.
• Selectus Direct Access PPO: is the name for Company’s non-gatekeeper PPO plan. Selectus Direct Access PPO is a network-based fully insured managed health care program that offers coverage for in and out-of-network services. Member do not select a PCP and may access care from either a participating or non-participating provider. The referral process is not applicable to Selectus Direct Access PPO Members. However, participating providers are responsible to request precertification/prior authorization for applicable services. Members may be responsible for copayments and/or deductibles and coinsurance. The terms and conditions of coverage for members enrolled in Selectus Direct Access PPO are defined in the Selectus Direct Access PPO Subscription Certificate.
• High Deductible Health Plan: This plan is similar to the Selectus Direct Access PPO plan, and does not require members to select a primary care provider or obtain referrals. Prior authorization/precertification is required for some services. All covered health care expenses are applied to the member’s deductible, except for certain preventive tests and services, which are covered at no cost to the member.
Because an HDHP member must first meet a deductible, providers should not collect any payment when services are rendered. A claim should be submitted to the Health Plan. The provider will then receive an explanation of payment (EOP) which will indicate the amount they should collect directly from the member.
High Deductible Health Plan members will have identification cards imprinted with the Selectus Direct Access PPO logo and “High Deductible Health Plan” on the front of the card. There will be no benefit code on this card; instead, a note will appear to remind providers that deductibles apply to this plan. The back of the card will include a reminder that this plan is offered by Geisinger Indemnity Insurance Company to avoid any confusion about the member’s insurance company.
• Geisinger Health Options: is the name used by Company in its role as a Third Party Administrator (TPA). Geisinger Health Options administers several different benefit options for self-funded employers. Employer-sponsored benefit programs may include HMO, HMO with POS, PPO or indemnity. The terms and conditions of coverage for members enrolled in Geisinger Health Options are defined in the employer-sponsored program’s Summary Plan Document.
• Geisinger Indemnity Insurance Company: In addition to serving as the parent company for Selectus Coordinated Care PPO, Selectus Direct Access PPO and Geisinger Health Options, Geisinger Indemnity Insurance Company is also the name for Company’s comprehensive major medical group indemnity insurance plan. Geisinger Indemnity Insurance Company offers a fully insured, comprehensive major medical group indemnity insurance plan to employers who need to provide coverage to employees living outside the service area. The terms and conditions of coverage for members enrolled in Geisinger Indemnity Insurance Company are defined in Geisinger Indemnity Insurance Company’s Subscription Certificate.
Any questions about a member’s eligibility, benefit coverage or the grievance and complaint procedures should be directed to:
Geisinger Health Options (TPA, Indemnity)
M-F, 8 a.m.-5 p.m. (800) 504-0443, (570) 271-8770
Selectus Direct Access PPO
M-F, 8 a.m.-5 p.m. (800) 504-0443, (570) 271-8770
Selectus Coordinated Care PPO
M-F, 8 a.m.-6 p.m. (800) 447-4000, (570) 271-8760
TDD for the hearing impaired M-F, 8 a.m.-4:30 p.m. (800) 447-2833
Geisinger Health Plan Gold is an HMO with a Medicare Advantage contract available to all Medicare beneficiaries residing in Blair, Cambria, Carbon, Clearfield, Clinton, Columbia, Dauphin, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Schuylkill, Snyder, Union, and Wyoming counties in Pennsylvania. Member must be enrolled in Medicare Parts A&B and must use a participating provider for health care services.
Gold Classic and Select coverage is in the form of a prepaid managed care gatekeeper product, which requires members to choose a Primary Care Physician (PCP) upon enrollment. The member must obtain a referral for covered services not provided by the PCP, excluding emergency services and direct access services. Members may be responsible for cost-sharing amounts in the form of copayments, deductible and/or coinsurance.
Gold members enrolled through their employer may also have access to an optional supplemental prescription drug or POS rider if their employer purchases such a rider.
Mental health and substance abuse services for the Gold members are required to be coordinated through OptumHealth Behavioral Solutions at (888) 839-7972.
SilverSneakers® Fitness Program is a total health and fitness program that is beneficial and free of charge to all Gold members of any fitness level. For a list of fitness centers participating with the SilverSneakers® Fitness Program, contact the Gold Customer Service Team.
Any questions about a Member’s eligibility, benefit coverage or the grievance and appeal procedures should be directed to:
Gold Customer Service Team
(800) 498-9731 or (570) 271-8771, Monday-Friday, 8 a.m. to 5 p.m.
TDD for the hearing impaired
(800) 447-2833, Monday through Friday, 8 a.m. to 4:30 p.m.
Claims should be submitted to the following address:
Geisinger Health Plan
P.O. Box 8200
Danville, PA 17821-8200