22
IRMC S ymetra P rogram H andbook Revised on 2/8/2018. View the most recent version at www.irmcdocs.org or contact us for updates.
IRMC
Symetra Program
Handbook
Revised on 2/8/2018. View the most recent version at www.irmcdocs.org or contact us for updates.
Table of Contents
2
3
4-5
4
5
6-9
6
7
7
8
8
9
9
10
11-14
11
12
13
13
14
14
15
16-17
16
17
Insurance Cards ---------------------------------------------------------
Medical Billing ----------------------------------------------------------
Table of Contents Page No
Symetra Program -------------------------------------------------------
Guide to Service ------------------------------------------------------------------
What’s Covered? -------------------------------------------------------
What’s Not Covered? --------------------------------------------------
Enrollment Agreement ------------------------------------------------
Cancelation Request ---------------------------------------------------
Forms ------------------------------------------------------------------------------
Partnering Providers -------------------------------------------------------------
Financial Assistance Program -----------------------------------------
Prescriptions ------------------------------------------------------------
Annual Income Verification ------------------------------------------
Medication Policy ------------------------------------------------------
Pharmaceutical Prescript. Patient Assistance Programs ---------
ER Visits and Hospital Admission ------------------------------------
Referrals to Specialists and Outside Providers --------------------
Obtaining Insurance ---------------------------------------------------
Policies & Procedures -----------------------------------------------------------
Eligibility Criteria -------------------------------------------------------
Federal Poverty Guidelines -------------------------------------------
Yearly Wellness Visits -------------------------------------------------
Welcome --------------------------------------------------------------------------
Contact Us! ------------------------------------------------------------------------
Eligibility Guidelines ------------------------------------------------------------
2
Primary Care
The heart of this program is connecting patients to
primary healthcare services. Patients establish and
coordinate their care with one of our providers.
Specialist Care
IRMC will cover in-network specialists and services if a
Symetra patient has a referral from their primary care
physician.
Hospital Care
Symetra provides our patients a safety net for affordable
access to IRMC Hospital.
We look forward to coordinating your healthcare together!
-IPG Social Services
Indiana Regional Medical Center (IRMC) and IRMC Physician
Group (IPG) are invested in serving the community’s healthcare
needs. Our Symetra program provides qualifying patients with
affordable healthcare options in three areas: hospitalization,
primary care, and specialty services. For an affordable monthly
premium, a patient’s enrollment will cover all in-network IRMC
and IPG providers; there is no deductible, and no co-pays.
Welcome
3
Questions about your coverage? Contact Us!
If you are unsure of whether or not a provider
accepts Symetra, or of how much of your care will be
covered, contact our team and ask!
Rachel Grove, MA, LSW
Alli Jensen, BSW
Julie Willis, BA
Bobbi Bradford, MSN, RN
Shannon Tepe, BS
Let us help coordinate your care within the IRMC network!
P: (724) 427 - 2763
F: (724) 349 - 3786
119 Professional Center, Suite 307
1265 Wayne Ave.
Indiana, PA 15701
Contact Us!
IRMC Physician Group Social Services
4
Please read the following policies and procedures carefully.
There are certain requirements that must be met in order to
maintain your eligibility as a patient with Symetra.
Failure to meet these requirements may result in dismissal from the program.
Eligibility Criteria
Patients between the ages 18-64 residing in Indiana
County, who meet the financial criteria annually. The
financial criteria are based on the that year’s Federal
Poverty Guidelines (pg. 5)
The Symetra program is not supplemental to
insurance. Patients must be uninsured. Patients who
qualify for medical coverage through Medicaid or
Medicare, or those with access to affordable insurance
though an employer are not eligible.
Examples of disqualifying health insurance include:
Private insurance (e.g. Aetna, Highmark, UPMC)
Medicaid
Medicare
Veterans Benefits
Eligibility Guidelines
5
Should your eligibility status change at any time, it is
your responsibility to inform IPG Social Services (pg. 3).
2018 Federal Poverty Guidelines
Household
Size
Plan I
($99.34)
Plan II
(169.99)
1 $24,280 $36,420
2 $32,920 $49,380
3 $41,560 $62,340
4 $50,200 $75,300
5 $58,840 $88,260
6 $67,480 $101,220
7 $76,120 $114,180
8 $84,760 $127,140
Eligibility Guidelines
6
The IRMC Symetra program was designed to provide
Indiana County residents access to affordable healthcare.
Primary care check-ups are an important part of good
health.
Patients are required to see their provider for a minimum
of one wellness visit per year. Establishing care with a
provider gives patients a place to go when they are sick.
Patients are to work with their primary care provider in
coordinating their healthcare. We encourage patients to
schedule as soon as their coverage becomes active.
To schedule an appointment with a provider, patients can call the
IRMC Physician Group Call Center.
IRMC Physician Group Call Center:
P: (888)-452-1762
For a complete list of doctors and specialties, visit:
www.IRMCdocs.org
Yearly Wellness Visit
7
Annual Income Verification
All patients are required to submit proof of gross family
income annually. Failure to do so may result in dismissal
from the program. Proof of income is due before May 1st
each year.
Examples of proof of income documentation include the
income tax return (1040, 1st pg.) or W2s.
Medication Policy
Prescriptions will be re-filled according to your primary
care office’s policy. If using a patient assistance program
through a drug company, patients must give at least two
weeks’ notice for re-fills. This allows for their medications
to be filled in time.
While Symetra patients may fill their prescriptions
anywhere, we recommend our patients use Gatti Pharmacy
to coordinate their prescription needs. Gatti Pharmacy has
agreed to offer some discounted pricing for Symetra
patients. Patients will receive a BeneCard PBF to present at
Gatti Pharmacy for discounts.
1024 Philadelphia Street
Indiana, PA 15701
P: (724) 349-4200
www.gattirx.com
Policies & Procedures
8
Many pharmaceutical companies require patients to be
denied Medical Assistance (MA) in order to qualify for
their program.
If a patient is asked to apply for Medical Assistance, they
should submit their application as soon as possible.
Patients can contact IPG Social Services to receive
assistance applying for MA.
Patients should read and follow through with any mail or
e-mails they receive from a pharmaceutical company.
Failure to follow up with a company may result in delayed
medication assistance.
ER Visits and Hospital Admissions
In the event a patient is hospitalized, or seen in the ER,
they may be asked to re-apply for Medical Assistance.
When in-patient, IRMC has a service which can assist
patients in applying for and obtaining Medical Assistance.
Please cooperate with this request, failure to do so may
result in dismissal from the program and full financial
responsibility.
Pharmaceutical Prescription Assistance Programs
Policies & Procedures
9
Referrals to Specialists and Outside Providers
Patients must be referred to a specialist by their IPG
primary care provider. Many independent specialists have
agreed to care for our patients for minimal or no cost. If
you are not sure whether or not your doctor is in network,
please call IPG Social Services. It is also very important
when scheduling with a specialist that all attempts are
made to attend the appointment. Please notify your
provider any time you obtain any type of insurance.
Maintaining a good relationship with our providers is vital
to ongoing support of the program.
Obtaining Insurance
Many of our patients obtain some type of insurance while
they are enrolled with Symetra. If you become eligible for
health insurance of any kind, please inform IPG Social
Services immediately. Examples of health insurance
include:
Private insurance (e.g. Aetna, Highmark, UPMC)
Medicaid
Medicare
Veterans Benefits
Upon receiving an insurance plan, patients should present
their new insurance card at any medical visit.
Policies & Procedures
10
Patients that are enrolled in Symetra must notify IPG Social
Services with any change in financial information prior to
3:00 PM on the 9th of that month to ensure that their
withdrawal is successful.
Patients will be terminated from the program if their
premium payment pull was unsuccessful two (2) times in a
twelve-month period. Patients will be sent a notification
of termination in the mail. Any patient who has been
terminated from the Symetra program is ineligible to apply
again for one year after the date of their termination.
If a patient decides to cancel their Symetra coverage, they
must complete a cancellation form, found at the end of this
handbook. The form must be submitted to the IPG Social
Services before 3:00 PM on the 9th of the month in order
to cancel automatic withdrawal for the following month.
The policies of the Enrollment Agreement may change at
any time without notice to you. By continuing to enroll in
the IRMC Symetra Program each month, you accept the
Enrollment Agreement as modified.
Symetra Program
Policies & Procedures
11
What's Covered?
Services within the IRMC & IRMC Physician Group network
are considered paid-in-full (no copays or deductible). In-
network services* include:
Office visits
Inpatient stays
Imaging
Lab work
X-rays
ER
UrgiCare
Pre-existing conditions are covered.
Services with our Partnering Providers (pg. 15) are
discounted at various levels. Patients are responsible for
any fees associated with these services after the discounts
have been applied.
Guide to Service
12
What’s Not Covered?
Unfortunately, IRMC does not offer all specialties (such as
dental). For unavailable specialties, patients will need to
go out-of-network.
Balance billing will apply with any services out-of-network
providers. Patients can contact IPG Social Services if a
doctor is referring them out-of-network.
The Ambulatory Center is physically attached to the
hospital, but is not covered. Surgeries must be scheduled
"in the hospital," or in the hospital’s Ambulatory Care Unit
on the 4th floor. Patients should be sure to discuss this
with their provider if it applies to them. Patients can
contact IPG Social Services if a doctor is referring their
surgery out-of-network.
Ambulance rides are not covered.
Guide to Service
13
Prescriptions
Patients will receive an identification card from BeneCard
PBF, to use at Gatti's Pharmacy for the Symetra discounts.
No other pharmacies will discount for Symetra patients,
but they may still have low cash prices.
If a prescription is still too expensive, medications may
qualify for assistance through the drug company. Patients
should discuss options with their provider. In addition,
patients can contact IPG Social Services for assistance.
Insurance Cards
Cards typically arrive 2-3 weeks after the first day a
patient’s Symetra coverage is active. However,
appointments can be made on the 1st day that your
coverage starts. If a patient is unsure when their coverage
will be activated, they are encouraged to call IPG Social
Services.
If a patient has not received their insurance card or if there
is a card error, patients should call the enrollment office
directly to request a card:
P: (814) 931 - 4312
Guide to Service
14
Medical Billing
If patients receive a bill and have questions, or suspect a
billing error, they should call IPG Social Services. Patients
can drop bills off at our office in 119 Professional Center,
fax, or e-mail them to us. Patients may be responsible for
any bills not brought to our attention within 90 days of the
date of service.
What is the Financial Assistance Program
(formerly I-CARE)?
This is a separate program that discounts a percentage
(based on family size and income), of IRMC & IPG medical
bills. It does apply retro-actively.
Symetra patients may apply for this program.
For information or to make an appointment, visit:
IRMC Financial Assistance:
www.indianarmc.org
P: (724) 471-1472
Guide to Service
15
There is a $25 copay for Indiana Total Therapy
Membership to the S & T Wellness Center is
discounted to $25/Month
Pathology applies a discounted balance billing
Dr. Barnicle (Gastroenterologist) accepts
Symetra as paid-in-full
Orthopedic needs are paid-in-full, but patients
may be asked to be evaluated by Physiatrist, Dr.
Taylor, for a referral to IRMC Orthopedics
X-rays related to your IRMC orthopedic visit may
be done on site. All other x-rays must be done at
IRMC imaging locations.
Shirley Eye Care gives our Symetra patients
discounted prices for eye care visits and glasses
Patients must present their Symetra insurance
card at all eye appointments to receive discounts
Dr. Nesper for Ophthalmology needs
Partnering Providers
For a complete list of doctors and specialties, visit:
www.IRMCdocs.org
Date: ________________________
Preferred Healthcare System
P.O. Box 1015
Duncansville, Pa 16635
EMAIL: [email protected]
FAX: 1.877-227-1753
I,__________________________________________ (patient name),
Would like to terminate my health insurance coverage through Symetra Life
Insurance Co. effective _______________________________ (date).
Sincerely,
_______________________________________Patient Signature
_______________________________________Patient Name (printed)
_______________________________________Patient Address
_______________________________________Patient City, State, Zip
*Please be advised, all cancellations must be received by the 9th of the
month at 3:00 pm in order to be processed for the 1st of the following
month, (e.g. If your termination is received January 9th, your policy will be
cancelled February 1. If your termination is received January 10th, your
policy will be cancelled March 1). Thank you.
CANCELLATION REQUEST FOR SYMETRA INSURANCE
I have read and understood the eligibility guidelines
for IRMC’s Symetra program.
I understand that the Symetra benefits do not apply
outside the IRMC network, and that it is my
responsibility to schedule my care within the IRMC
network.
I realize that I am responsible for any medical bills or
balance billing accrued from Partnering Providers
and out-of-network providers.
I am aware that if my eligibility status changes at any
time, it is my responsibility to inform the IRMC
Physician Group Social Services department.
Patient Signature Date
Patient Name (Print) DOB
Call the IRMC Physician Group Social Services with any questions!
ENROLLMENT AGREEMENT
Program Disclaimer
The policies of the Enrollment Agreement may change at any time. The IRMC Physician Group Social Services will make
reasonable efforts to announce changes in the program to members. By continuing to enroll in the IRMC Symetra Program each
month, you accept the Enrollment Agreement as modified.
