PHP, Georgia

Dr. Eugene Paul
AHF Provider

How to Get Medical Services

Current enrollees, learn about changes to PHP (HMO SNP) for 2019.

 

Using PHP (HMO SNP) is easy.  You will get most of your care through your primary care provider (PCP).  Your PCP is listed on the front of your member ID card.  If you are seeing a different PCP than the doctor named on your member ID card, please contact Member Services so we can update our records and give you a new ID card with the correct provider on it.

You can change your PCP whenever you’d like for any reason.  If you’d like to change your PCP, please contact Member Services.

If you need specialty care, your PCP will refer to the specialist that you need.  You may self-refer to certain specialists for the services listed below without seeing your PCP first:

  • Routine women’s health care, which includes breast exams, screening mammograms (x-rays of the breast), pap tests and pelvic exams, as long as you get them from network women’s health providers like gynecologists
  • Flu shots and pneumonia vaccinations as long as you get them from network providers
  • Dental care as long as you get it from network dentists
  • Vision care as long as you get it from network optometrists
  • Emergency services
  • Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or in accessible, for example, when you are temporarily outside of Broward or Miami-Dade County (the plan’s service area)
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

You generally must receive your care from a network provider.  In most cases, care you receive from an out-of-network provider will not be covered.  There are exceptions:

  • The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
  • If you need medical care that Medicare requires us to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Authorization should be obtained from us prior to seeking care.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

You can find a PHP network provider by using our online Network Provider/Facility/Pharmacy Search application or downloading the provider directory for your county.


 

Detailed information about how to use the plan and its covered services is in the 2018 Evidence of Coverage and 2019 Evidence of Coverage.

If you want to get a health care service, but are not sure if it is covered you can ask us to make a coverage decision.  Detailed information about coverage decisions is available in Chapter 9 of the 2018 Evidence of Coverage and 2019 Evidence of Coverage.

If we have made a coverage decision about a service you want to get or already received and you do not like it, you can make an appeal.  Detailed information about making an appeal is in Chapter 9 of the 2018 Evidence of Coverage  and 2019 Evidence of Coverage.  If you would like to know the aggregate number of grievances and appeals filed with PHP for prior and current year, please contact Member Services.

If you ever have any questions about PHP, please do not hesitate to contact Member Services.


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