How to find a TotalCare (HMO D-SNP) provider

A primary care provider (PCP) is a health care professional or clinic that provides medical care. You will need to pick a TotalCare network PCP to coordinate all your health care needs. Your PCP can do many things for you, like:

• Support your health care needs.
• Give you regular check-ups, immunizations and help when you are sick.
• Help prevent health problems or manage chronic health issues, like diabetes.
• Refer you to other providers when you need it.

Your PCP can be one of the following, depending on your health needs:

• General practitioner.
• Internist.
• Family practitioner.
• Geriatrician.
• Clinic.

You can also choose a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) as your PCP. These are health centers in areas without many health care service options.

You must pick a PCP in the TotalCare network at the time you enroll. If you do not, we will assign you a PCP. You can change your PCP at any time. To find a PCP near you, go to the online Provider/Pharmacy Directory or call Member Services.

If you don’t choose your PCP when you first enroll, you can do so by filling out the Choose Primary Provider form online. You can also call Member Services for help.

Over time, your PCP will get to know your health history and help you make choices that support your health and well-being. Your TotalCare Member ID card will include the name of your PCP’s provider group.

Use the Provider Directory to find your PCP or health care specialist. You may need a referral from your PCP before making an appointment with a specialist for non-emergency care. Call your PCP or Care Coordinator to find out if you need a referral.

There are three ways to find a provider:

• Search the online Provider Directory.
  • Select “TotalCare” in the Health Plan accordion menu.
  • Choose a provider type.
  • Check the box for “Accepting New Patients."
    Read our tutorial if you have more questions about how to use the online directory.

• Download the Provider/Pharmacy Directory.
• Get a printed directory mailed to you.
  You can use our online form to ask for a printed directory mailed directly to you. You can also call Member Services and ask them to mail one to you. To find a provider in the printed Provider/Pharmacy Directory:
  • Find the Primary Care Provider section in the Table of Contents.
  • Choose a town that is close to you and go to the page number listed for that town.
  • Check if the provider or clinic is accepting new patients. Above the wheelchair picture is a line that says Accepting Patients. If there is a Y, that means that new patients are being accepted.

To change your PCP, call Member Services. You can also fill out the Choose or Change Primary Provider form. The change will go into effect on the first day of the following month. If you change your PCP, we will mail you an updated TotalCare Member ID card.

If your current primary or specialty care provider isn’t part of the TotalCare network, you might still be able to see them for a certain amount of time. This is called continuity of care.

You can keep getting the same care (continuity of care) if all these things are true:

• You saw a provider or specialist who is not in the TotalCare network at least once in the last 12 months for a non-emergency visit;
• That provider agrees to be paid by TotalCare using Medicare’s payment rates; and
• That provider has not had any problems with the quality of their care that would make TotalCare decide not to include them in our network.

If your provider does not join the TotalCare network by the end of 12 months, does not agree to Medicare’s payment rates, or does not meet quality of care requirements, you will need to switch to a provider in the TotalCare network.

What if I change my health plan or switch from Fee-for-Service (FFS) Medicare into managed care?

You might be able to keep your provider, even if they are not in the TotalCare network, under continuity of care. If you need to get care from a primary or specialty care provider who is outside the TotalCare network, call TotalCare Member Services to ask about continuity of care.

You could possibly keep your provider even if you:

• Change your health plan.
• Switch from FFS to managed care.
• Had a provider who was in your previous plan’s network but is now outside the TotalCare network.

To learn more about continuity of care, eligibility and services, contact Member Services, Monday through Friday from 8 a.m. to 8:00 p.m. If you need language assistance, we have a special telephone line to get an interpreter who speaks your language at no cost to you. For the Hearing or Speech Assistance Line, call 800-735-2929 (TTY: 711).