Understanding Roles and Responsibilities within PERACare
Understanding how insurance works can be overwhelming, but we’re here to help.
Here’s a breakdown of roles and responsibilities so you can better understand who makes important plan decisions and be a more informed PERACare enrollee.
PERA staff
The PERACare team is responsible for selecting carriers (we use competitive proposal processes), determining which plans are offered, and setting the level of some benefits, such as copays and deductibles. Other responsibilities include:
- Reviewing premium renewals with carriers
- Ensuring that carriers meet PERA’s contractual performance standards
- Collecting monthly premiums from enrollees
- Ensuring plans are in compliance with health insurance regulations
PERACare carriers
PERACare carriers like UnitedHealthcare and Kaiser Permanente determine what’s covered under each plan, including which services need prior authorization and which providers and medications the plan will pay for. They also are responsible for:
- Calculating the premium required to cover the expected claims for each plan year
- Processing prior authorization requests from providers
- Providing customer service and care management services to enrollees
- Helping you determine the cost of medical services prior to getting services
Providers (doctors, hospitals, etc.)
The doctors, dentists, specialists, and other providers you visit determine what kind of health care you need, from diagnosing ailments to prescribing medication and answering questions. Your providers are also responsible for:
- Determining when a prior authorization is required and submitting that request to the carrier
- Identifying alternatives if a particular service or medication is not covered
- Filing claims to your insurance carrier on a timely basis
- For dental care, submitting a pre-treatment estimate so you know your cost in advance
You
As an enrollee in a PERACare plan, it is important to read and carefully consider all PERACare information we send to you, as well as all information from your carriers. Your responsibilities also include:
- Providing requested documents to PERA for eligibility determination
- Contacting your carrier for help with a claim or to request a new ID card (but please contact us if you can’t resolve an issue on your own)
- Updating PERA if your address or phone number changes
- Paying your Medicare Part B premium (if enrolled in a Medicare plan)
