Capital Health Plan FAQs

General Questions

Q. How does Capital Health Plan work?

A. Capital Health Plan is a health maintenance organization (HMO). We not only insure you against the high cost of medical care, we actually provide medical care through our broad network of physicians and service providers for a small copayment. Members should never see a claim form. We handle all the paperwork and details. Your primary care physician is continuously involved in managing and coordinating your health care.

Q. What benefits are included?

A. Our coverage for you includes preventive care, diagnostic and lab tests, hospital and surgical care, and inpatient and outpatient treatment and emergency care. For details, please go to Benefits below or refer to your Capital Health Plan Member Handbook.

Q. How much paperwork and claim forms are involved?

A. Practically none. There are no claim forms. Also, our Member Services representatives are just a phone call away at 383-3311 to answer any questions you may have concerning Capital Health Plan's benefits and policies.

Q. If I have a medical need at a time other than routine office hours, will I have access to a physician?

A. Yes. Your primary care physician (PCP) is either on-call, or has another physician on-call, 24 hours a day, 7 days a week. Also, CHP offers its members an Urgent Care Center. After hours, you call your PCP's office for guidance about the problem. He or she may want you to go to CHP's Urgent Care Center, which is located in the Centerville Road health center. The Urgent Care Center is open weekdays noon-ll p.m., and weekends, 9 a.m. - 8 p.m. (Members whose PCPs are affiliated with Patients First will go to Patients First for after-hours care.)

Q. Am I covered for medical emergencies?

A. Yes. A medical emergency is an accidental injury or the sudden and unexpected onset of a condition requiring immediate medical or surgical care. Some problems are emergencies because if not treated promptly, they might become more serious; examples include deep cuts and broken bones.

Q. How do I handle emergency situations?

A. When a medical emergency occurs inside or outside the service area, go to the nearest medical facility for treatment or call 911. Then contact your primary care physician's office as soon as possible. Capital Health Plan should be notified within two working days. Your PCP will authorize medically necessary hospitalizations and provide or arrange any needed follow-up care within the CHP network.

Q. Does Capital Health Plan provide coverage when a member is living away from home?

A. You are covered for emergency care (as defined above) 24 hours a day, every day, anywhere in the world. Also, CHP's popular Away from Home Care® Program allows any commercial employer group member to have coverage when living temporarily outside of our service area for at least 90 consecutive days (a covered dependent going to college, for example). These CHP members may become guest members of any participating HMO in the BluesCONNECT® network. This network is the nation's largest, including health plans in over 200 cities.

Physicians

Q. May I choose my own primary care physician (PCP)?

A. Yes. Each member chooses a primary care physician from our directory of internists, family physicians, and pediatricians. Your PCP is responsible for the management of all your health care, from regular check-ups in the physician's office to more specialized treatment or hospitalization, should that become necessary. Each member of your family selects his/her own primary care physician, for example, you may choose either a pediatrician or a family physician for each child. You can see a list of our primary care physicians in our network directory.

Q. May I see a gynecologist for my annual pelvic exam?

A. Yes. CHP provides members direct access (no referral needed) to a gynecologist within our network once a year for a pelvic exam, PAP smear, and breast exam. You may use Physician Search on this site to find obstetrician-gynecologists in our network. Some members are accustomed to having their annual exam with their primary care physician and prefer to continue doing so.

Q. Does every member of my family have to use the same primary care physician?

A. No. Each family member may choose a different primary care physician.

Q. May I change primary care physicians?

A. Yes. If, for any reason, you wish to change your primary care physician, you may do so easily by calling a Member Services representative at 383-3311. Your change will be effective the first day of the following month.

Q. Does Capital Health Plan offer any primary care physicians who are in private practice?

A. YES! Capital Health Plan offers you a choice of many physicians in private practice offices throughout the community. In fact, your current physician may be a provider for the plan.

Q. How can I find out which Capital Health Plan affiliated primary care physicians are currently accepting new patients?

A.On occasion, a particular affiliated primary care physician (PCP) may not be accepting new patients. If you are already a patient of a CHP-affiliated PCP when you enroll in CHP, that doctor can continue to see you under Capital Health Plan. Otherwise, to find out which primary care physicians are currently accepting new patients, check our Network Directory and look for the colored flag (red, yellow, or green) under "status" on the doctors record. You may also call our Member Services representatives at 850-383-3311 to obtain the most current information.

Q. What happens if I need to see a specialist?

A.When appropriate, your primary care physician will refer you to a participating specialist if he or she cannot personally provide the care you need.

Q. What happens if I am already seeing a specialist at the time I enroll in Capital Health Plan?

A.If the specialist you are seeing is participating in Capital Health Plan's local network, then your care may continue without the need for a referral from your primary care physician. If the specialist is not participating in Capital Health Plan's local network, then you should consult your primary care physician regarding a referral to a participating specialist. You may see CHP's extensive list of participating specialists in our Network Directory.

Services, Benefits and Programs

Q. What services are available to members at Capital Health Plan's health centers?

A. CHP's two health centers are located at 2140 Centerville Road (across from the U.S. Post Office) and 1491 Governor's Square Boulevard (near the movie theaters). In addition to doctors' offices, both health centers offer x-ray services, a lab, and eye care centers-including a huge selection of glasses at low, competitive prices. The Centerville Road facility also houses the CHP Urgent Care Center. At the Governor's Square Boulevard center, CHP's new Mammography Screening Center is helping many members receive this crucial service faster. Most health education programs are also held at the Governor's Square center.

Q. Are the Capital Health Plan health centers like a clinic?

A. No. Each primary care physician (PCP) at a Capital Health Plan health center has his or her own office suite and staff and sees patients by appointment only. If you have chosen a PCP who practices at a center, you access all of your routine medical care from that PCP. If you are sick, every effort will be made to schedule you to see your primary care physician. If he or she cannot see you, the staff will arrange for you to see another physician within the health center.

Q. What if I need lab services, x-rays, or diagnostic testing?

A. Your primary care physician or participating specialist will coordinate such care and make necessary referrals for service.

Q. Where can I obtain information about Capital Health Plan's quality improvement program?

A. The purpose of Capital Health Plan's quality improvement program is to provide our members with high quality, safe and affordable healthcare. Quality improvement activities focus on improving the health status of our members. Click on the links below to review a copy of our Quality Improvement Program and Workplan, and an evaluation of the status of our quality improvement activities. If you would like additional information, or need a copy of these documents mailed to you, contact our Member Services department at (850) 383-3311.

QI Program Description 2009 (pdf 507.05 kB)

QI Program Evaluation 2008 (pdf 70.16 kB)