Frequently Asked Questions
HMO Guide
This page summarizes some of the most frequent questions members ask about using your HMO benefits. PacFed is dedicated to providing you with quality health care and service. The more you understand how your Health Plan coverage works, the better your ability to use the services available. The Member Services Department is available to provide you with assistance when you need it. For more information or answers to other questions regarding coverage, please contact the Member Services Department at PacFed Benefit Administrators (PacFed).
What is a Primary Care Physician?
The foundation for Health Maintenance Organizations (HMO) is your relationship with your Primary Care Physician. A Primary Care Physician is usually a general practitioner or family practice physician who manages all your health care or medical needs, which includes your basic care, preventive services, referrals to specialist and hospitalization arrangements.
Always contact your Primary Care Physician first for any health care needs. Your Primary Care Physician or associate is available 24 hours a day.
How do we choose the right Primary Care Physician?
Use the Provider Directory to select a physician nearest to your home or work. Your medical records will be maintained at your selected Primary Care Physician.
How do I use my medical identification card?
You will each receive a medical identification card with you and your eligible dependents selected Primary Care Physician's name, address, phone number and your personal identification number. Carry your card at all times and have it available when you call or visit your doctor.
What if I need to see a specialist?
Your Primary Care Physician, in consultation with his/her colleagues, will determine the proper treatment and refer you to a specialist when needed.
Ask your Primary Care Physician how long the referral authorization takes. If you feel the referral process is taking too long, call the PacFed Member Services Department for assistance.
Remember: All medical care must be coordinated by your Primary Care Physician, or the cost of the service may not be covered.
Can I change my Primary Care Physician?
Yes. You may change Primary Care Physicians once a month. You will need to Anthem Blue Shield’s Member Services Department.
Changes made by the 15th of the month to be effective the 1st of the following month.
What is an emergency?
An emergency is defined as an illness or injury that threatens a person's life.
What if my doctor's office is closed and I need medical care?
For non-life threatening conditions you should call the 800 number on the back of your medical identification card for instructions. If your condition is life threatening or may cause permanent damage to your health or limb, call 911. Once your condition is stable you or a family member should call the 800 number on the back of your identification card to report your medical emergency. The Plan must be notified within 48 hours.
What if I need to see a doctor while away from home?
Your Medical Plan will cover urgent care or medical emergencies when you are out of the service area. Your co-payment will be slightly higher for urgent care and medical emergencies.
Will I receive any medical bills?
It is possible you may receive a bill in error. If you ever receive a bill for charges other than applicable co-payments, do not pay it. Forward the bill to the PacFed Member Services Department:
PacFed Benefit Administrators
200 S. Los Robles, Suite 320
Pasadena, CA 91101
(818) 243-0222
(800) 753-0222
Fax: (818) 549-0610
Where and how often can I get my prescription filled?
Most prescriptions can be filled at well known chain drug stores. However, some pharmacies are located in the same buildings as your Primary Care Physician or next door. To be sure, ask the office manager of your Primary Care Physician. Long term medications can be purchased by mail. Call the Health Plan Member for a mail order form.
PPO Guide
This page summarizes some of the most frequent questions members ask about Using Your PPO Benefits. PacFed is dedicated to providing you with quality health care and service. The more you understand how your Health Plan coverage works, the better your ability to use the services available. The Member Services Department is available to provide you with assistance when you need it. For more information or answers to other questions regarding coverage, please contact the Member Services Department at PacFed Benefit Administrators (PacFed).
What is a Preferred Provider?
A Preferred Provider typically accepts the health plan's Allowable Amount as payment for covered services. All you pay is your applicable Preferred Provider co-payment. Non-Preferred Providers can charge more than these amounts. When members use Non-Preferred Providers, they must pay the applicable co-payment plus an out-of-pocket cost, which is typically much greater than the cost to see a preferred Provider.
How do I find a preferred provider physician?
You may use any provider listed in the health plan's PPO Preferred Provider Directory. The PPO Provider Directory may be accessed online through this website.
How do I use my medical identification card?
You and your eligible dependents will each receive a medical identification card. Carry it with you at all times and have it available when you visit your doctor or have a prescription filled.
What is an emergency?
An emergency is defined as an illness that threatens a person's life.
Where and how often can I get a prescription filled?
Most prescriptions can be filled, in thirty-day supplies, at well-known chain drug stores. Long term medications can be purchased by mail. Call the health plan or PacFed Member Services for a mail order form.
What if I need to see a doctor while away from home?
You can also access the Provider Finder, an online provider directory on HealthNet’s website at healthnet.com. Click on Find A Provider and scroll to the bottom of the page where you will see the First Health Provider link.
Do I have to receive prior authorization for certain services?
You are responsible for obtaining prior authorization for certain services, including inpatient surgeries, hospital stays and outpatient surgeries. If you have a life threatening emergency, however, please seek immediate care and then secure the necessary authorization.
How will my claims be paid?
When you use a PPO Preferred Provider, the service will be paid at the highest level and your co-payment minimized. The provider will send the claim to the health plan and receive reimbursement directly from the health plan. The health plan will send you a Explanation of Benefits detailing what was paid on your behalf.
Will I have difficulty finding a PPO provider outside California?
No. First Health, the national PPO provider for Health Net, coordinates with out of state providers. These providers are located on Health Net’s website under the Provider Search area. Scroll down to the bottom of the page and click on the First Health provider link.
What Is A Health Savings Account (HSA)?
A Health Savings Account (HSA) is a type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you can lower your overall health care costs.
Family and Medical Leave Act (FMLA)
Under the Family and Medical Leave Act of 1993 (FMLA), you may be entitled to family or medical leave. If you are eligible and elect to take FMLA leave, your coverage under the Plan will continue with no interruption of active employment until the earlier of the end of such leave, or the date you notify your employer you do not intend to return to work at the end of the FMLA leave.
Continued active participation in the Plan while on FMLA leave will be at your option. Employers are responsible for funding the same portion of the employee's premium that they paid before FMLA leave. Employees are responsible for funding the same portion of the premium that they paid before the FMLA leave. If you elect not to continue your benefits during the FMLA leave, your coverage will be reinstated without regard to any pre-existing condition limitation on your return to active working status on or before the end of the FMLA leave.
A leave taken under FMLA does not constitute a COBRA qualifying event unless the employee fails to return to work at the end of the FMLA leave. In that case, the last day of FMLA leave would be the qualifying event date for COBRA. You must contact your employer to determine your eligibility for FMLA leave.
If you have any questions about this notice please contact:
PacFed Member Services
1-818-243-0222
HIPAA
Health Insurance Portability and Accountability Act of 1996
The intent of the HIPAA legislation is to improve the availability and portability of health coverage by:
Restricting preexisting condition exclusions and limitations;
Providing credit for prior coverage to reduce or eliminate preexisting condition limitations;
Providing new rights to enroll in plans in situations when other coverage is lost;
Prohibiting discrimination on the basis of health status; and,
Guaranteeing the availability and renewability of health coverage for small employers
See more about HIPAA in the Summary Plan Description.
COBRA
Consolidated Omnibus Budget Reconciliation Act
Should your coverage through Musicians Health and Welfare be terminated, due to a COBRA qualifying event, you will have the opportunity to continue your coverage on a self-pay basis.
See more about COBRA in the Summary Plan Description.
Questions?
The Fund is administered by PacFed Benefit Administrators (PacFed). Our bilingual staff can help you with enrollment, coverage and HMO claims.
PacFed’s core goal is to ensure that members understand their plan and how to use their benefits effectively. Our Member Services department is available Monday through Friday, 8:30 a.m. to 5:00 p.m. at 1-800-753-0222 or email musicians@pacfed.com.