Want to learn more about the Synergy and Summit networks? This page answers some of the most commonly asked questions.
What is the difference between a Synergy or Summit CCM plan and a PPO plan?
The Synergy and Summit plans are based on a coordinated care model (CCM) using the more focused Synergy and Summit networks, each focusing on different counties in Oregon (see questions #2 and #3 for list of counties), while a statewide PPO plan uses the wider Connexus network and does not connect you to a specific clinic to manage your care.
When you choose a PPO plan, you can have lower out-of-pocket costs when you use any provider practicing within a Connexus Medical Home, but you do not need to select one specific Medical Home to coordinate your care.
The Synergy and Summit plans do require you to select a Medical Home within the network and see providers within that Medical Home for all primary care services. Both the PPO plans and the Synergy/Summit plans have out-of-network benefits available, but you will be responsible for higher out-of-pocket costs when using out-of-network providers (and, on the Synergy and Summit plans, when seeking primary care outside your selected Medical Home).
Another benefit to Synergy and Summit plans is that premium costs are typically lower for these plans than for PPO plans using the statewide Connexus network. If you would like to compare rates, they are available at http://www.oregon.gov/oha/OEBB/Pages/Plans-Offered.aspx. These rates only reflect the base rate, and do not factor in the amount that your employer would contribute. Check with your human resources or payroll department to find out more about the rate you would pay.
Where are Synergy plans available?
These plans serve members living or working in most of western and central Oregon. Synergy plans cover the following counties:
Benton, Clackamas, Clark, Clatsop, Columbia, Crook, Deschutes, Douglas, Hood River, Jackson, Jefferson, Josephine, Klamath, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Tillamook, Wasco, Washington and Yamhill. Check with your human resources or payroll department to find out if Synergy plans are available to you.
Where are Summit plans available?
These plans serve members living or working in eastern Oregon. Summit plans cover the following counties:
Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa and Wheeler. Check with your human resources or payroll department to find out if Summit plans are available to you.
What is the difference between the Synergy and Summit CCM plans?
The Synergy and Summit networks have the same Medical Home requirements and the plans work the same. The difference between them is their service areas. The Synergy network focuses on western and central Oregon, while Summit focuses on eastern Oregon.
Depending on your employing entity and location, you will likely have only one or the other available. If you have both available to you, choose the one that covers the area in which you will receive care. While there is some overlap in service area and some providers are contracted with both, Synergy and Summit providers cannot be used interchangeably. Make sure that your provider is in-network with your specific network in order to receive the highest benefits available.
What is a Medical Home?
If you are hearing the term "Medical Home" for the first time, you're probably wondering what it means. How does it work? How is it different from the way you've been receiving healthcare?
In the past you have likely seen a number of doctors and other providers and because they worked on their own, providers may not have had a formal way to work with each other to care for you. A Medical Home changes that. It is a team-based approach to healthcare. You can still have one doctor or primary care provider who works with the rest of your team to bring the best care to you, or you can see any primary care provider within your Medical Home and trust that you won't need to start over with every visit. This model is becoming more and more popular in healthcare.
Here are the three things you should know about a Medical Home:
See modahealth.com/medicalhome for more details.
Do I have to select a Medical Home on a Synergy or Summit plan?
Yes, you and each dependent covered under your plan will need to choose a Medical Home. Each dependent can choose a different Medical Home if they desire. The Medical Home you choose will coordinate your care, and you need to see a provider within your selected Medical Home for primary care services in order to receive the in-network benefits available under your plan.
Do I have to choose an individual doctor or can I see anyone in my Medical Home?
Each member will choose their own Medical Home and can see any PCP at that clinic for their primary care services.
Can I keep the primary care provider I am using today?
If your current PCP is part of a Synergy or Summit Medical Home (depending on which network your plan uses), then yes, you will be able to keep using this provider and select the clinic as your Medical Home. If not, you can contact Medical Customer Service at 1-866-923-0409 for help locating a Medical Home to which you can transfer your care.
What if I see a PCP that is not in my selected Medical Home?
If you seek primary care services from a provider who is not in your selected Medical Home, then the claim will be paid at a lower benefit level and subject to the out-of-network deductible and out-of-pocket maximum.
Are Medical Homes required to accept new patients?
Medical Homes are not required to accept new patients. If you are not currently using a provider within a Synergy or Summit Medical Home, you will need to check with your desired Medical Home to verify availability before selecting them. Moda continually updates information received from providers regarding whether or not their specific home is accepting new patients, but availability can always change, so it is a good idea to check with the home.
Where can I find a list of Medical Homes?
How do I select a Medical Home?
You will select your Medical Home through Moda Health, and must do this as soon as possible after your Synergy or Summit plan becomes effective. If you are new to the Synergy or Summit plan, Moda Health will mail you step-by-step instructions on selecting a Medical Home along with your ID cards, after enrolling on the plan. Your selection can be made one of the following ways:
When do I need to select my Medical Home?
It is recommended that you select your Medical Home as soon as you receive your welcome packet from Moda. If you have a primary care office visit prior to making a Medical Home selection, your claim will be paid at a lower benefit level and subject to the out-of-network deductible and out-of-pocket maximum.
Can I change my Medical Home throughout the year?
Yes, if at a later date you or a family member wants to change your Medical Home, you can do so. In order to change the Medical Home, members will need to select their new Medical Home and communicate the change to Moda Health using the options provided above. This change will be effective the first of the month following the notification of your new selection.
Do I have to re-select a Medical Home each year?
No. Your selection will carry over from year to year.
After enrolling, what can I expect when calling into Moda customer service?
The Customer Service Representative (CSR) will review to see if you and each dependent covered under your plan has selected a Medical Home. If there is no Medical Home on file, the CSR can assist you in locating and selecting one over the phone. The CSR will then review with you the benefits of receiving coordinated care through the Medical Home to ensure you receive the highest level of benefits possible.
Are there referral requirements?
Your Medical Home will coordinate care, including specific recommendations to certain specialists and hospitals. While these providers may require a referral from your Medical Home, one does not need to be on file with Moda Health. It is important to note, though, that you must still make sure that you are using in-network providers for all care. Otherwise, benefits will be paid at a lower benefit level and may be subject to the higher out-of-network deductible and out-of-pocket maximum.
What if there is no nearby specialist in-network?
If there is no in-network provider available with a particular specialty, the Medical Home will work with Moda Health to coordinate the referral to ensure in-network benefits.
What do I need to tell my doctor's office after selecting the Medical Home?
You should provide the doctor's office with a copy of your ID card and tell them that you are part of Moda's Synergy or Summit network and you have selected them as your Medical Home. Encourage them to call Moda Health or check online to verify benefits; this will help ensure that you receive the highest level of benefits and the best quality care possible.
If I have a non-emergency issue on the weekend, my Medical Home is not open, and I go to a walk-in clinic like ZoomCare/Zoom+, how will my claim be paid?
Some facilities are considered same-day/walk-in primary care or specialty clinics, and though they may function similarly to urgent care clinics, they are not considered under the same benefits as urgent care clinics. If you are receiving primary care or specialty services rather than urgent care services, that care would fall under the primary care or specialty benefits on your plan. If you are seen at one of these clinics for primary care and they are not your selected Medical Home, benefits will be paid at a lower benefit level and may be subject to the higher out-of-network deductible and out-of-pocket maximum.
ZoomCare/Zoom+ is one example. It is classified as a same-day PCP and is also a Medical Home, therefore, if you saw a ZoomCare/Zoom+ doctor and they were not your preselected Medical Home, the claim would be paid at the lower benefit level. To find urgent care providers in the Synergy or Summit network, please visit Find Care, our Provider Search tool.
I see a naturopath for my primary care. Can I select my naturopath as my Medical Home?
Alternative care providers (naturopaths, chiropractors and acupuncturists) are considered specialists. Alternative care providers or specialists cannot be designated as a Medical Home. Members can, however, see an alternative care provider for primary care services. The claim will be paid according to the specialist office visit benefit level.
What about emergency care?
Claims for emergency care will be paid at the in-network benefit level, and emergency care does not need to be coordinated via the Medical Home.
What about my dependent who does not live in the Synergy or Summit service area?
Dependents living and accessing care outside the service area do not need to select a Medical Home; however, if out-of-area dependents plan to access primary care while visiting home within the service area, they should select a Medical Home to use while in the service area in order to receive the in-network benefit level.
If you have a dependent planning to live outside the service area, make sure to update their address by using your MyOEBB account or by contacting your employer's human resources or payroll department. Effective the first of the month following the request or address update, the dependent's plan will be updated to allow out-of-area care at the in-network benefit level according to the terms outlined in your member handbook. You can also contact Moda Health at 866-923-0409 to have the plan updated, but you will still need to update the dependent's address in MyOEBB.
I am an OEBB retiree or COBRA member living outside the Summit or Synergy service area. Can I choose a Synergy or Summit CCM plan?
Choosing a Synergy or Summit plan requires that you live or work within the service area. Therefore, retirees and COBRA members who reside outside of the services area will need to choose a PPO plan.
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