Yes. Employee and their covered spouse must select a contracted Primary Care Clinic/Physician. The Primary Care Clinic/Physician can differ between the Employee and their covered spouse.

Yes. However, you are REQUIRED to contact ACTIN CARE GROUPS to advise the name of the primary care doctor you will see. Your ID Card will show the PCP information as: Other-Notify Actin. You will be responsible for paying the bill when you visit your doctor and you will be reimbursed at ACTIN’s median contracted rate for in-network physicians. You will be responsible for the difference, if any, in what the physician charges and the Plan pays. You can submit your itemized billing statement to the claims address on the back of your card for reimbursement. It is important you notify ACTIN Care Groups with your primary care doctor information so claim reimbursements for this provider are processed correctly.

It is your responsibility, not your NON-contracted Primary Care Provider’s, to notify ACTIN Care Groups for a referral to a contracted ACTIN Specialist. If you are referred by a NON-contracted ACTIN Primary Care Provider to a NON-contracted Specialist, you will bear the full cost.

Ask your provider to refer you to ACTIN preferred labs; Quest Diagnostics, LabCorp, Health Labs and Alverno Labs. You can find the logos on your ID card as well.

No. Covered dependent children can see any of the contracted Primary Care Clinics/Physician.

Yes. The employee and covered spouse can change their Primary Care Clinic/Physician ONCE a year by contacting ACTIN Care Groups directly. ACTIN Care Groups will confirm the Effective Date of the newly assigned Primary Care Clinic/Physician.

You will pay a $75 penalty if you see a contracted Primary Care Clinic/Physician that is not your assigned Primary Care Clinic/Physician. Even though you pay the penalty expenses, they do not count toward the out-of-pocket limit.

Yes, you need to obtain a referral from your Primary Care Clinic/Physician to see a Specialist. The penalty for not preauthorizing a specialist visit is $75 in addition to applicable coinsurance per visits. Even though you pay the penalty expenses, they do not count toward the out-of-pocket limit. You can obtain a referral authorization from your PCP or by calling ACTIN at (866) 420-8575.

Your covered dependent residing more than 25 miles from the Employer’s zip code six months of the year or more can access Providers under the First Health Network (The First Health Network logo and contact information will be on the ID Card for you to access). The URL for provider look-up is www.firsthealthcomplementary.com. If the covered dependent does NOT access a First Health PPO provider, you will be responsible for the full charges.

To avoid unexpected costs, you MUST notify ACTIN Care Groups when: member is PREGNANT, member is a STUDENT living OUT OF AREA, and when PCP on your ID Card says OTHER -NOTIFY ACTIN.

At the Employer’s site annually, ACTIN will perform a Blood Draw, Measure Height, Weight, Blood Pressure and Administer Lifestyle Questionnaires.

Employees and Spouses who are in ACTIN Care plan at the time of the Well Check is performed at the worksite are eligible to participate in the Well Check. Employees hired after that date are not eligible until the next Plan Year, if applicable. To schedule the WellCheck, contact ACTIN directly at (866) 420-8575.

The WellCheck Action Items include:

• Blood Draw, Measurement of Height, Weight, and Blood Pressure;
• Answer Lifestyle Questionnaire which can be completed on smart phone or computer;
• Follow up with PCP for an exam to review the results within 5 months of performance of the Well Check or of enrollment in the Plan, for members who enroll later;
• Employees & Spouses who report Smoking or whose Lab Tests indicate smoking should bring a letter from their PCP that they have either attended at least THREE smoking cessation sessions with their PCP by the end of the Plan Year or provide ACTIN a letter from their PCP that they have stopped smoking. There is NO COST for these sessions or for medications to help in smoking cessation;
• Employees & Spouses who are diabetic as determined by the results of the WellCheck (A1C > 6.5%) should attend at least TWO Nutritional/Diabetic Counseling sessions or achieve an average A1C less than 8% by the end of the Plan Year. There is NO COST for Nutritional/Diabetic Counseling. Services are available in English and Spanish.

Yes. Employees and Spouses who choose NOT to participate in the Wellness Program at all or do not follow through with the minimum number of sessions for smoking and/or nutritional/diabetic counseling sessions (if applicable) will owe the Employer $500.

ACTIN provides helpful reminder Text messages sent monthly of any outstanding Well Check Action Items to avoid any unexpected costs and provides detailed instructions in a sealed envelope 2-3 weeks after the Well Check is performed at the work site.

IN-NETWORK Urgent Care providers are in the First Health Network when traveling outside the following counties: Boone, Cook, Dekalb, DuPage, Kane, Kankakee, Lee, McHenry, Stephenson, Will, and Winnebago (The First Health Network logo and contact information will be on the ID Card for you to access.) You can search www.firsthealthcomplementary.com to find a First Health urgent care center outside the Chicago/Rockford areas.

You are covered at any hospital in an emergency. You may be asked to complete a financial assistance form after a Hospital or Emergency Room admission. If you are asked to complete this form and do so, your cost will not be more than your coinsurance and copays. If you decline to complete the financial assistance form, you will owe the difference in what the plan pays and the hospital charges in addition to applicable copays and coinsurance.

Emergency Room Care includes a facility copay plus coinsurance. The copay is waived if admitted. Note: ER visits are all reviewed by an independent physician to determine if the condition was in fact an emergency. An “Emergency” is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in 1) a condition placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. Medically unnecessary ER visits are not covered. If unsure whether to go to the ER or Urgent Care, call the 24 hr Nurseline at 800-583-5888.

You are responsible for your share of the coinsurance amount.