Questions and answers about care navigation

What is care navigation?

Starting April 1, 2022, care navigation is a new medical coverage feature offered by the Board of Pensions in partnership with Quantum Health to help members enrolled in the PPO, EPO, and HDHP options and their covered family members navigate their healthcare and use their medical benefits.

Who is Quantum Health?

As a recognized expert in the field of care navigation, Quantum Health is dedicated to supporting and guiding individuals on their healthcare journeys. Part of good stewardship means finding the best business partners who share our values and can create positive health outcomes for our members. With more than 20 years of experience, Quantum Health brings the specialized clinical expertise and healthcare industry knowledge needed by the Board of Pensions to carry out our mission.

What’s changing as of April 1?

As of April 1, 2022, Quantum Health replaces Highmark Blue Cross Blue Shield for specific services for members enrolled in the PPO, EPO, or HDHP.

  • Quantum Health will be your primary point of contact for help with issues such as verifying covered services and benefits, answering questions about claims and provider bills, and replacing lost ID cards.
  • Quantum Health will also handle precertification of medical services when required and help with complex care situations; for example, if you require an inpatient hospital stay or need ongoing care or services on an outpatient basis or in your home.
  • You will continue to use the national Blue Cross Blue Shield (PPO BlueCard) network, and Highmark will continue to process medical claims.
  • You will receive new medical and prescription ID cards to use beginning April 1. The back of the medical ID card lists the services that must be precertified with Quantum Health. The precertification process helps ensure you are receiving the right care in the right setting.
    Important: The list is slightly different from the current precertification list and includes additional services, such as outpatient surgeries, home health care, hospice care, and, depending on its cost, durable medical equipment.

Note: Since the benefits provided by the Medicare Supplement Plan are coordinated between Medicare and Highmark Blue Cross Blue Shield (BCBS), members enrolled in that plan will continue to contact Highmark BCBS with questions. Members with medical coverage through Triple-S and GeoBlue have unique benefits and will continue to contact those plans as before.

Why is the Board introducing care navigation?

As healthcare has grown increasingly complex, the Board of Pensions wants to help members continue to have successful health outcomes. By providing care navigation across all three medical options (PPO, EPO, and HDHP), we add significant value for employees and their covered family members. As reflected in our Theology of Benefits, we are stewards of resources designed to promote wholeness and provide the best possible benefits to members within our financial means. Through care navigation, members have access to their own personal support team of nurses, clinicians, and benefits specialists, resulting in a superior healthcare experience at no additional cost to the employer or employee.

Can I still call the Board of Pensions if I have a question?

We are committed to serving our members and are proud of the unique relationships we have built over the years. While Quantum Health will be equally committed to supporting you on your healthcare journey, we are still here for you. The Board remains your primary contact for questions about eligibility, retirement, and other benefits besides medical. With that being said, you can still call the Board with any questions, as we are always here to serve. If your question can be best answered by Quantum Health, we will transfer the call and remain on the line until you are connected with a Care Coordinator.

What does it cost?

There is no cost to members or employers. Care navigation is another way that the Board of Pensions provides enhanced value to members and their covered family members as well as to employers. Through our careful stewardship of resources, we are making this investment in member experience to deliver this resource at no cost to members and employers.

Will I get a new ID card?

New medical and prescription drug ID cards will be mailed in March. You should begin using your new cards starting April 1, 2022.

The back of the medical ID card lists the services that must be precertified with Quantum Health. The precertification process helps ensure you are receiving the right care in the right setting.

Important: The list is slightly different from the current precertification list and includes additional services, such as outpatient surgeries, home health care, hospice care, and, depending on its cost, durable medical equipment.

The ID card will also include a dedicated phone number and website your provider can use to verify your coverage.

What kinds of things can Quantum Health help with?

Quantum Health Care Coordinators are available to help with anything that can make the healthcare process easier. Quantum Health can help you

  • find the right provider;
  • understand your benefits and how a claim was paid;
  • order replacement ID cards;
  • manage a health condition;
  • save money on out-of-pocket costs (such as finding network facilities instead of an out-of-network facility a healthcare provider has suggested);
  • understand how to get the most out of your benefits; and
  • learn simple steps to improving health.

Are the benefits provided by the plan changing?

Care navigation complements PPO, EPO, and HDHP medical coverage through the Board of Pensions; plan benefits remain the same.

  • Deductibles, coinsurance, copay amounts, and out-of-pocket maximums are not changing.
  • The same medical care and services, including behavioral health and prescription drugs, are covered by the plan.
  • You still have access to the same Blue Cross Blue Shield national provider network.
  • Highmark continues to pay medical claims and provide explanation of benefits (EOB) statements.
  • Express Scripts continues to administer prescription drug benefits.

Important: While plan benefits remain the same, the list of services that must be precertified is expanded effective April 1, 2022. Services that must be precertified with Quantum Health include inpatient and skilled nursing facility admissions; outpatient surgeries; MRI/MRA/PET scans; oncology care and services; genetic testing; dialysis; transplants; home health care; hospice care; durable medical equipment (all rentals and purchases over $1,500); partial hospitalization and intensive outpatient care for behavioral health/substance use.

Do I have to connect with a Quantum Health Care Coordinator?

If you prefer a self-service approach, you can use the Quantum Health portal (through Benefits Connect or directly) or mobile app to access benefits information, find network providers, download a medical ID card, and more.

You can also continue to use express-scripts.com to order or refill home delivery prescriptions, use the Price a Medication tool, and download a prescription ID card, just as you normally would.

What if I’m currently working with a Highmark nurse?

If you have been working with a Highmark nurse case manager, a Quantum Health Care Coordinator will reach out to you about transitioning to Quantum Health. Starting April 1, if you see Quantum Health on your caller ID, your Care Coordinator is trying to reach you.

If you don’t want to wait until a Quantum Health Care Coordinator contacts you, you can get started by calling Quantum Health and asking to speak to a nurse. The toll-free number for Quantum Health will be provided before April 1 and will be listed on your new ID cards as well.

What if I’m currently working with the Member Advocate at the Board?

If you have been working with the Board on any issue, you will continue to do so. The Member Advocate may work with you and Quantum Health to provide additional support for you in your healthcare journey. Quantum Health will also handle precertification of medical services and work closely with you and your family on complex care situations, including hospital stays and support for ongoing health conditions.

I am planning to retire. Will care navigation be included in the Medicare Supplement Plan?

The success of care navigation is largely based on the interactions that Quantum Health has with Highmark Blue Cross Blue Shield and Express Scripts and how those interactions contribute to personalized support for you and your family members enrolled in the PPO, EPO, or HDHP. Medicare does not work with organizations like Quantum Health, so Quantum isn’t able to impact or support your care through the Medicare Supplement Plan to enhance outcomes in the same way. However, Highmark and the Board of Pensions continue to be available to help with questions about the Medicare Supplement Plan, services that are covered, providers, and explanation of benefits (EOB) statements.

What support is available for employees whose primary language isn’t English?

For employees whose primary language is Spanish, Quantum Health Care Coordinators who are fluent in Spanish are ready to assist with any requests or healthcare needs. Translation services are available for other languages, including Korean.