- What is the Wayne County Four Star Health Program (WCFS)?
- Doesn’t Wayne County already have a three-share program with Health Choice? How is WCFS different?
- Why offer another three-share program?
- What health systems are involved in the WCFS program?
- What are the goals of WCFS?
- Who is eligible for WCFS?
- Are dependents eligible for coverage?
- If an employee had health insurance with a previous employer and gets a new job with an employer eligible for WCFS, is that employee eligible for WCFS?
- What kind of health coverage do members get from WCFS?
- Where can members of WCFS get medical services?
- Are prescription drugs covered?
- Do WCFS members have access to the home delivery pharmacy service through Medco?
- Are referrals or prior authorizations needed to receive care?
- Who should members contact with questions regarding coverage and benefits?
- Do WCFS members have mental health benefits?
- Who do providers call when they have questions?
- What happens if a service is not a covered benefit, or if a member’s coverage has already been used up this year?
- What benefit does a member get from WCFS when their coverage runs out or something is not covered?
- Will providers become bill collectors?
- If someone has health insurance coverage through their spouse, Medicare or Medicare HMO, Medicaid or Medicaid HMO, or through the Armed Forces are they eligible for WCFS?
- If someone has coverage through Health Choice today, can they change to WCFS?
- How much does WCFS cost and who pays the premium bills?
- Can a member join WCFS for 6 months, disenroll for 3 months then join again?
- Can part time or seasonal employees join WCFS?
- Are pre-existing conditions covered or are their limitations on coverage ?
- How are the providers supporting WCFS?
1) What is the Wayne County Four Star Health Program (WCFS)? The Wayne County Four Star Health Program is a non-profit Michigan corporation organized to provide health coverage for the working uninsured in Wayne County. It is known as a ‘three-share’ program because the employer, the employee, and the non-profit funds each share one-third of the monthly premium cost of the program.
The Wayne County Four Star program is a new network and new community product under Alliance Health and Life Insurance Company (AHL).
2) Doesn’t Wayne County already have a three-share program with Health Choice? How is WCFS different?
Yes, Wayne County does have a three-share program called Health Choice, which is operated by the county and serves about 4,000 members. The difference with WCFS is that it will be operated by the health systems (St. John Health, Detroit Medical Center, Henry Ford Health System, & Oakwood Healthcare System) in collaboration with the County. WCFS is not managed by Wayne County. There are also small differences in the rates, who is eligible and the coverage provided by the two different programs. This provides small business with more choice
3) Why offer another three-share program?
The addition of WCFS will more than double the number of Wayne County’s uninsured residents with access to quality health services.
Current estimates suggest that there are 250,000 uninsured residents in Wayne County. By offering employers a choice of coverage programs, we hope to be able to offer coverage to about 10,000-15,000 members through both programs.
The number of enrollees is limited by the amount of public funding available to cover one third of the premium.
4) What health systems are involved in the WCFS program?
The Wayne County Four Star program includes Henry Ford Health System, Detroit Medical Center, St. John Health and Oakwood Healthcare System. In addition, Alliance Health and Life Insurance Company (AHL), a wholly owned subsidiary of Health Alliance Plan, underwrites the program. Wayne County along with the above health systems founded the program.
5) What are the goals of WCFS?
• The WCFS goal is to provide the working uninsured individuals in Wayne County an employer based, affordable, basic health coverage product.
• By having basic coverage through WCFS, the members will gain access to needed medical care without the worry of paying the full cost of care.
• The WCFS product also allows small employers to offer a health care benefit to attract good employees, reduce turnover and foster a healthier, more productive work force.
• WCFS will also reduce the amount of uncompensated care to our hospitals, a cost that has to be passed along to all the insured residents in Wayne County.
6) Who is eligible for WCFS?
Employers must meet the following eligibility requirements for WCFS:
• Primary business location is Wayne County,
• Be an employer of 2-100 employees,
• Employees must have a median wage of $16/hour (or less)
• 50% of those employees live in Wayne County
• In addition to these requirements, a group cannot have offered health coverage to its employees in the past 12 months. However, some exceptions are made in special hardship situations. Please call 866-780-6655 to see if your group qualifies.
7) Are dependents eligible for coverage?
Members are encouraged to enroll their children in the MIChild or Michigan Medicaid programs. If MIChild or Medicaid has denied coverage for a child, the child may be enrolled in Four Star. Proof of denial will be required for enrollment.
Significant others, and adult dependents are not eligible. WCFS is a LIMITED benefit program with LIMITED eligibility targeting the working uninsured of Wayne County.
8) If an employee had health insurance with a previous employer and gets a new job with an employer eligible for WCFS, is that employee eligible for WCFS?
Yes after completing 90 days of service with a new employer that already is offering WCFS, the employee is eligible to enroll with WCFS. If the new employer is not now offering WCFS, but decides to offer it to their employees, the new employee is eligible at open enrollment for the entire group.
9) What kind of health coverage do members get from WCFS?
WCFS provides basic level of coverage using an Exclusive Provider Organization (EPO) plan. This means the plan has affordable co-pays but not all services are covered, and there are annual limits on the amount of coverage offered by type of service. For example, the annual maximum benefit limit for all services is $35,000 per person and the lifetime maximum benefit is $200,000 per person. Coverage for inpatient hospital service, outpatient services, physician surgery services, maternity services, and emergency services all have annual coverage limits. The reason for this basic plan design is to ensure that the monthly premium is affordable for the employers and employees.
It is important for members to understand with the “Exclusive Provider Network” that if they receive care for non-emergency services out of network, the members are responsible for the cost of the care.
10) Where can members of WCFS get medical services?
WCFS members can receive care through the four health systems, (Henry Ford Health System, Oakwood Healthcare Systems, Detroit Medical Center and St. John Health) and their hospitals that are located in Wayne County. To receive care from a personal care physician (PCP) or a specialist, referrals are not needed, but members must receive care from the network physicians listed in the provider directory. As long as members receive covered medical care from a participating hospital and doctor, the services are covered through WCFS. If a member receives care from a non-participating hospital or doctor, except in an emergency situation, they are not covered through WCFS.
The participating hospitals are:
Detroit Receiving, Harper, Hutzel,
Henry Ford, Oakwood Annapolis, Oakwood Heritage,
Oakwood Southshore, Oakwood Dearborn, Sinai Grace,
St. John Riverview, and St. John
11) Are prescription drugs covered?
Yes, prescription drugs are covered. Generic drugs have a $5.00 per prescription co-pay. Brand name drugs have a 50% co-pay with a $25.00 minimum co-pay per prescription. For example, if a brand prescription total cost is $45.00, the member’s co-pay will be the $25.00 minimum. If the brand prescription total cost is $70.00, the member’s co-pay will be 50% or $35.00. The pharmacy network is contracted through Alliance Health and Life Insurance Company, so most all of the major drug store chains and local pharmacies in Wayne County participate.
12) Do WCFS members have access to the home delivery pharmacy service through Medco?
No. Experience with other three-share programs has shown that members benefit from being able to discuss their medication questions with their local pharmacists, and patient outcomes improve.
Members will be able to have their prescriptions filled at over 475 pharmacies located conveniently throughout Wayne County.
13) Are referrals or prior authorizations needed to receive care?
To receive care from a personal care physician (PCP) or a specialist, referrals are not needed, but members must receive care from the network physicians listed in the provider directory.
Pre-certification is required for all elective inpatient hospital care, the admitting physician (or PCP) is required to call AHL and get pre-certification for the elective admission at 313-664-8950 or 1-800-926-3436. In addition, on the day of the elective admission, the hospital is required to call AHL at 1-888-477-7587.
For emergency care, prior approval is not required. If the member needs to get admitted for inpatient care, we require the hospital to call AHL within 48 hours of the non-life threatening emergency admission at 1-888-477-7587 and follow the prompt to be connected to the Prior Authorization department. For life-threatening emergencies requiring admission prior approval is not required.
For behavioral and substance use care, members need to call Coordinated Behavioral Health Management (CBHM) to get directed to a provider that can meet their needs.
14) Who should members contact with questions regarding coverage and benefits?
Members enrolled in WCFS should call 1-(888) 477-7587 and follow the prompt to be connected to the Client Services department. Client Services Specialists are available Monday through Friday from 8:00a.m. to 5:00p.m and Saturday from 8:00a.m. to noon.
Employees who are not enrolled can call 1- 866-780-6655 and someone will be available to help them
15) Do WCFS members have mental health benefits?
Yes, mental health and substance use services must be pre-certified by our Coordinated Behavioral Health Management (CBHM) department and delivered by a provider affiliated with the Wayne County Four Star program. For more information, members can call CBHM directly at 1-800-444-5755. CBHM staff is available Monday through Friday from 8 a.m. to 5 p.m. for routine services. In an emergency, members can call CBHM 24 hours a day, 7 days a week and staff is available to assist them.
16) Who do providers call when they have questions?
Providers can call the Provider Relations department directly at (313) 664-8075 or toll free at 800 -688-0040. Provider relation’s staff are available from 8:30 a.m. to 4:30 p.m. Monday through Friday
Providers not yet affiliated with WCFS can call 1- 866-780-6655 and someone will be available to help them.
17) What happens if a service is not a covered benefit, or if a member’s coverage has already been used up this year?
Services that are not a covered benefit or services received after a member’s annual coverage amounts have been used for the year are the responsibility of the member to pay. For example, if a member needs emergency services and the benefit is limited to $1,000 per visit, the member will be responsible for covered services in excess of $1,000.
18) What benefit does a member get from WCFS when their coverage runs out or something is not covered? WCFS will work with members to help them access other public or private sources of care that may provide needed services for free or at reduced rates. For example, local health centers have sliding fee scales based on the patient’s ability to pay for services.
If a member is responsible for payment, the payment amount should be agreed to between the doctor or hospital and the patient. The four health systems participating with WCFS have their own charity care programs for which the members may be eligible.
19) Will providers become bill collectors?
Today when someone seeks care and doesn’t have insurance, the provider is the bill collector; this is a normal part of their business. It is not uncommon for a provider to write off a bill as non-collectible when a patient has no insurance and cannot afford to pay the bill. When a member has WCFS coverage, the provider gets reimbursed up to the limits of the member’s policy, and both the member and the provider know that once the coverage is exhausted, the member is responsible for services.
20) If someone has health insurance coverage through their spouse, Medicare or Medicare HMO, Medicaid or Medicaid HMO, or through the Armed Forces are they eligible for WCFS?
No. If someone has other health insurance coverage or if they are eligible for Medicare, they are not eligible for WCFS. The WCFS program is intended for employees who do not have health insurance today.
21) If someone has coverage through Health Choice today, can they change to WCFS?
No. To be eligible for WCFS, the employer must not have offered health coverage to the eligible group of employees within the last year. If they had Health Choice coverage, they must wait at least a year without coverage before they are eligible for WCFS.
22) How much does WCFS cost and who pays the premium bills?
The employer, the employee and the non-profit will each pay $62.50 per member per month or a total of $187.50 per month. If an employee has a dependent spouse they are covering, the rate will be an additional $187.50 per member per month. In general, the employer will pay $62.50 for the employee (and dependent if the employer chooses to pay for this share) the employee will have payroll deduction pay their $62.50 share. AHL as the underwriter will bill the employer $125 per month for each member and dependent spouse enrolled (this is the employer’s and the employee’s share), and will bill Metro Health for the remaining $62.50 share.
23) Can a member join WCFS for 6 months, disenroll for 3 months then join again?
No. A member must stay enrolled with WCFS if they are with their same employer. If they disenroll, they must be without health insurance for one year before they can re-enroll in WCFS. If they change employers and the new employer offers WCFS, the employee can enroll after 90 days of continuous service with the new employer.
24) Can part time or seasonal employees join WCFS?
To be eligible for WCFS, employees must be working at least 20 hours per week for at least 90 days. The employee’s job must be expected to last at least 6 months or longer, so seasonal employees are not eligible.
25) Are pre-existing conditions covered or are their limitations on coverage ?
There are no exclusions for pre-existing conditions . The WCFS partners believe that we can improve the quality of care and reduce overall cost, by encouraging and covering access to wellness services and treatment for chronic conditions such as asthma, diabetes or high blood pressure. There is a $1,000 limitation on first-year payments for pre-existing conditions.
26) How are the providers supporting WCFS ?
The providers participating with Wayne County Four Star through Alliance Health and Life are accepting discounted fees for the services they provide. In this way, the providers are part of the community partnership to help improve coverage and access to high quality health services.
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