WHAT YOU NEED TO KNOW ABOUT YOUR COVERAGE
Delivering trusted and understandable information to our members about their health plan is a core part of the Common Ground Healthcare Cooperative (CGHC) mission. We really don’t believe in fine print.
The resources here on this page describe what you need to know about your health coverage. Updating these documents to make things easier to understand for our members is an ongoing project at CGHC, and we welcome your feedback if you’d like to provide some.
What you’ll find here:
- Your Certificate of Coverage is a legal document describing the health services our health plans cover. Things that are not covered are described in this document and in the Exclusions and Limitations Things that require advanced approval by us are described on the Understanding Prior Authorization page.
- Covered Prescriptions is our drug list, otherwise known as our formulary.
- Our Provider Networks will take you to our searchable directory. If you are not covered through your employer, you can be certain you are in our Envision network.
- If you have a serious medical condition, please visit our MemberCare Program We may be able to offer you additional support while you are healing or coping with a chronic condition.
- Rights and Responsibilities and the Notice of Privacy practices include information about our efforts to keep your personal information protected and what you can do if you disagree with a decision we make. It also describes your responsibilities as it pertains to keeping your out of pocket costs as low as possible.
It is important to us that all members understand their rights as a CGHC member. Our members have the right to:
- Receive information about CGHC, its services, its practitioners and providers and Member rights and responsibilities.
- Be treated with respect and dignity by CGHC employees, contracted providers, vendors, and health care professionals.
- Privacy and confidentiality regarding their health and their care.
- Participate with practitioners in making decisions about their health care.
- A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
- Voice complaints or concerns about CGHC or any of its network providers.
- Appeal any decision made by CGHC and to receive a response within a reasonable amount of time.
- Make recommendations regarding CGHC’s Member rights and responsibilities policy.
- Choose an advance directive to designate the kind of care they wish to receive should they become unable to express their wishes.
- Have a safe, secure, clean and accessible health care environment.
- Have access to emergency health care services in cases where a “prudent layperson” acting reasonably would believe that an emergency existed.
Given that the health of CGHC members impacts the financial wellbeing of all other CGHC members, those that purchase our insurance also have certain responsibilities. It is the responsibility of our members to:
- Pay their premiums.
- Comply with all provisions of the policy outlined in the Certificate of Coverage, including Prior Authorization requirements.
- Know and confirm their benefits before receiving treatment.
- Show their ID card before receiving health care services.
- Follow agreed upon instructions and guidelines for care.
- Understand their health problems and develop mutually agreed upon treatment goals, to the degree possible.
- Provide accurate information, to the extent possible, that CGHC and their practitioner require to care for them, or to make an informed coverage determination.
- Use practitioners and providers affiliated with their health plan for health care benefits and services, except where services are authorized or allowed by their health plan, or in the event of emergencies.
- Pay appropriate co-payments, coinsurance and deductibles to participating practitioners and providers when services are received.
- Pay full charges incurred for non-covered services; PPO subscribers to pay balance remaining for out of network services: EPO subscribers to pay full charges for out of network services.