FREQUENTLY ASKED QUESTIONS FOR EMPLOYERS
What is CooperativePlus?
CooperativePlus was established in 2005 as Patient/Physician Cooperatives (PPC), an organization of patients, physicians and member representatives, with two clinics in Houston, Texas. Since then, the organization has grown to 125 clinics distributed throughout the Houston area and beyond, including clinics and employer groups in Oregon, Arizona, New Mexico, and Oklahoma.
In 2017, PPC established CooperativePlus as a business name for member services.
How is CooperativePlus different from insurance?
CooperativePlus is a healthcare system focusing on wellness and comprehensive healthcare services. It provides members easy access to affordable, medically necessary services at affordable rates.
Unlike most insurance companies, CooperativePlus has no exclusions for age (under 65), income, or pre-existing conditions.
By creating this comprehensive system, incorporating medical discount programs, and a variety of Association Group or Employer Sponsored insurance plans, CooperativePlus has simplified access to a high quality healthcare.
Why do we focus on primary care?
The main focus of CooperativePlus is continuity of care to achieve and to maintain wellness.
We encourage members to develop real relationships with their providers. This allows members to seek healthcare before their issues become critical. The primary care provider offers services such as general health and wellness exams, diagnosis and treatment of acute and chronic conditions.
What if the employee doesn’t want to switch from his or her current provider?
The plan is open to providers nominated by their patients. It’s easy for a physician to join CooperativePlus. The patient can call Member Services at 1-866-549-4199 and refer his or her doctor. We will contact the medical service provider to inquire whether that practice would like to accept CooperativePlus members.
What if the employee needs a specialist?
CooperativePlus has an excellent group of specialists for in-network referrals, and we’re constantly expanding. Members can see any of our provider members for reasonable rates.
If a patient needs to see a specialist outside of our network, CooperativePlus has access to other networks to facilitate access to care. Our patient advocates will work with members to bring the costs down to Medicare equivalent rates.
What is patient advocacy and why is it so important?
Patient Advocacy is one of the most important benefits of the CooperativePlus model. The CooperativePlus Patient Advocacy Team performs care coordination to ensure all of the entities that participate in the members’ healthcare programs work together. They protect against excessive billing practices and support high quality medical outcomes.
When can the employee elect to make changes to his or her coverage?
The Health Plan is administered under the guidelines of Section 125 of the IRS code, which allows deductions for federally recognized dependents to be taken on a pre-tax basis, but also limits changes to the plan to an annual Open Enrollment period.
What if the employee is in an active course of treatment with an out-of-network doctor when your company enrolls in the plan?
Our plan has a transition of coverage program for members who are in an active course of treatment and whose treating provider is not a CooperativePlus provider.
What if I enroll in a medical plan mid-year and some employees have met some or all of their deductibles under a prior plan?
The plan will provide deductible credit for amounts met during the same contract year while a member was covered by a previous plan. In order for deductible credit to be applied, employees MUST submit proof of prior deductibles paid to the Plan Supervisor for processing. An Explanation of Benefits (EOB) from the prior carrier or a deductible credit report, outlining the deductibles met within the current calendar year, is the best way to report this information.
Are there limits on prescription medications?
Our pharmacy plans include pre-certification and quantity limit provisions. Programs like pre-certification encourage the safe, cost-effective use of prescription medications. Pre-certification allows coverage of certain medications only when certain conditions are met and usually applies to medications that are likely to be taken inappropriately for too long of a period, should only be prescribed for certain conditions, or tend to be more expensive than other medications proven to be just as effective.
Are there any limits to medical coverage?
The CooperativePlus plan covers services that are medically necessary.
Does the health plan have a coordination of benefits provision?
Yes. If this plan is secondary coverage to another health plan, it may make additional payment for covered expenses after any applicable deductible is met. This additional payment is made only to bring the total payment by the combined plans to the amount that this plan would have paid if it were the only coverage.
Therefore, dual enrollment in two plans that cover the same types of benefits (i.e. two medical plans or two dental plans) should be considered carefully as the benefits may not outweigh the costs.
Can the employee continue coverage after he or she is no longer eligible for group coverage?
If an employee loses coverage under the plan for certain reasons, such as a reduction in hours, death of a spouse, or divorce, he or she may be entitled to obtain continued coverage under COBRA or a similar applicable state mandated law.
Please note that if your worksite group ceases participation in the health plan, COBRA or similar coverage extensions will also terminate at that time. If your company ceases participation in the plan, the employees may be able to continue coverage under any replacement plan applicable to your worksite group.
Does the Plan meet the Minimum Creditable Coverage (MCC) requirements of the PPAACA?
That sounds great! How do I apply?