Individual Plans (2014)

Read our latest FAQs to help you determine if our plan is the right plan for you!

Q: Who is eligible to apply?

A: Generally, you must live in our service area (Brevard and Indian River Counties in Florida), and be between 19 and 64-1/2 years of age. Applicants younger than age 19 can only apply if they are classified as an emancipated minor, or if a parent or legal guardian has in-force coverage, or is also applying and approved for individual coverage. For more information, contact us or your broker.

Q: Can I see any doctor I want?

A: We encourage you to choose your personal doctor, known as a primary care physician (PCP), from our network of physicians. Primary care physicians are family and general practitioners, internal medicine physicians, and pediatricians. The primary care physician coordinates all of your medical care, including offering preventive care, ordering necessary laboratory, x-ray, and other routine diagnostic tests, arranging for hospital admissions, and working with specialists when medically necessary. All primary care physicians are on call 24 hours a day, 7 days a week. If you need urgent care after normal office hours, call your primary care physician to coordinate your care or visit one of our participating urgent care providers.

Q: Do I need referrals to see specialists?

A: There may be occasions when a medical service is needed that your primary care physician is unable to provide. Health First Individual members have "open access" to see specialists without first obtaining a referral from their PCP. When treatment is required from a specialist, you may contact specialist offices to make appointments as necessary and pay the applicable copayment at the time services are rendered.

It's important to note that while Health First Individual does not require referrals for specialty care in our network, we recommend you establish a relationship with your PCP and seek services from him or her before seeing a specialist. By becoming "established" with a network PCP, youâ??ll be able to receive care in the event your doctor no longer accepts new patients. Your PCP will help make sure youâ??re seeing the appropriate specialist, and also keep track of all your medications to reduce the chance of any complications. Plus, many times your PCP will be able to get you an appointment with a specialist more quickly than if you tried on your own. Therefore, we urge you not to discount the advantages offered by PCPs to assist in coordinating your entire spectrum of care.

Q: What if I need urgent or emergency care when I'm out of town?

A:Your health is always our most important concern. In case of an emergency, go to the closest medical facility or call 911. Health First Individual will provide coverage for any emergency medical condition, anywhere in the world. An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

-serious jeopardy to the health of a patient, including a pregnant woman or fetus;
-serious impairment of bodily functions; or,
-serious dysfunction of any body organ or part.
-there is an inadequate time to safely transfer to another hospital prior to delivery;
-a transfer may pose a threat to the health and safety of the patient or fetus; or,
-there is evidence of the onset and persistence of uterine contractions or rupture of the membranes

Urgent or walk-in care
If you need care right away but your condition is not a true emergency, call your primary care physician to coordinate your care. All primary care physicians are on call 24 hours a day, 7 days a week. If your PCP cannot see you quickly enough, visit one of our participating urgent care or walk-in clinics listed in the ancillary section of this directory. No appointment is needed.

These urgent care and walk-in providers can treat sinus and ear infections, colds, bronchitis, strep throat, pink eye, strains, minor burns, skin infections, rashes and cuts. Urgent care centers can also treat minor fractures and cuts that need stitches.

Visiting an urgent care center or walk-in clinic instead of a hospital emergency department can often save you time and money.

Q: Do I need authorizations?

A: While Health First Individual does not require a referral to see network specialists, there are certain services that require prior authorization, regardless of whether you use in-network or out-of-network providers.. This ensures that the right care is provided in the right setting. In-network physicians have information on the services that require prior-authorization from the health plan and the steps required to obtain approval. Some examples of services that require prior-authorization include MRI, PET, CT scans and nuclear cardiology studies.

If you are using an out-of-network provider, please be sure youâ??ve discussed the authorization process with your provider and have notified Health First Individual in advance of receiving care. You have the ultimate responsibility to notify your non-network provider that authorization is required for these procedures. For more information on which procedures require prior authorization or how to obtain approval, please contact our Customer Service department.

Q: How are these Health First plans different than the others?

A: All Health First individual plans include gym memberships at local participating fitness centers giving you access to running tracks, pools, the latest equipment and classes like Zumba, yoga, cycling and more!

Plus, many of the other plans restart your deductible (the amount you have to pay before the plan pays) at the beginning of the calendar yearâ??regardless when you bought the coverage. With Health First, your deductible lasts one year from when you start your coverage.

Q: What services are covered?

A: Covered services include doctor office visits, urgent care, emergency care, inpatient hospital care, lab care, radiology, specialty therapies, outpatient surgery, home health care, skilled nursing facility, and mental health services. For more information, ask your broker, contact us, or see your contract.

Q: What services are not covered?

Services that are excluded from coverage include any service not medically necessary, elective cosmetic surgery, infertility services, abortion, alternative medical treatments, genetic testing, obesity treatment, any service not listed in the contract or rider (unless required by state law). For more information, ask your broker, contact us, or see your contract.

Health First Individual health insurance policies are underwritten by Health First Insurance, Inc. Applications are subject to eligibility requirements. Exclusions and limitations may apply. Health First Insurance has entered into an agreement with CMS to provide health insurance coverage through Qualified Health Plans on the Federally Facilitated Marketplace. For more information, contact your agent or your local Health First Insurance office.