The administrator and network provider of the Focus Plan is Centivo. The Focus Plan provider network includes Cone Health facilities and physician practices as well as a large number of THN independent and community physicians. You can find the list of network providers at https://conehealth.centivo.com/. This plan has a limited local provider network, so it is NOT an appropriate plan for anyone who lives out of the local area or has covered dependents outside of the Triad or if you are currently getting treatment from an out-of-network physician and you want or need to continue to go to that practice. It is important to understand that the United Healthcare (UHC) Choice Plus Network is not part of the Focus Plan network. Out-of-network coverage is limited to urgent care (2 visits annually), emergency-only and virtual visits.
The Focus Plan is built around a partnership between you and your personally selected Primary Care Team (PCP). Your Primary Care Team will help you navigate the healthcare system by providing referrals to Specialists. It is your responsibility to verify that Specialist referrals made by your PCP to you are physicians who are in the Centivo network. You must then provide your visit referral information to Centivo.
Click Here to view a copy of the Summary of Benefits Chart.
Focus Plan Brochure | Focus Plan FAQs | View Webinar (Access Code: cZ?5uJP7)
How It Works
Step 1: Activate your Account by mobile app or phone; be sure to list your PCP with Centivo. If you are already in the Focus Plan and activated, you do not have to activate again.
Step 2: Develop a care plan with your PCP. If Specialists are part of that care plan, you MUST get referrals for specialists from your PCP and then notify Centivo prior to receiving care. This referral does not have to be in writing, but it does have to be documented in your PCPs notes. You self-report the referral on the Centivo app or by phone. Referrals are good until the end of the plan year.
Step 3: Follow the care plan of your PCP.
If you follow Steps 1 through 3, and all of the coordination of care steps are followed, your claims will be processed as “Coordinated Care.” If you do not get a referral, do not notify Centivo of the referral prior to treatment, or have your physician get the proper authorization approvals for your care, your claims will be processed as “Uncoordinated Care.”
Important Change for 2021
In situations where medically necessary services are not available from any Cone Health or THN network provider or facility, your Cone Health primary care physician may request a network exception through Centivo for you to receive an evaluation or care outside of the Cone/THN network. This is made possible through arrangements that Cone has with providers at Duke Health and Wake Forest Baptist Hospital. In the event neither Duke nor Wake provide the necessary services, another approved provider will be identified by Cone Health. Incidents that may qualify for an exception involve urgent, unforeseen illness or medical conditions requiring imminent and timely medical attention, such as a need for organ transplants, burn care and pediatric surgeries. Out-of-network referrals will also be made to provide for legally-required plan benefits not otherwise available from Cone/THN network providers.
If an exception is granted for a requested referral outside of the Cone/THN network during a plan year, and it involves a chronic condition that will require further treatment in a future plan year, you can continue your enrollment in the Focus Plan and the medically necessary out-of-network treatment for that ongoing condition (presuming Cone does not then have an in-network provider). If, however, the approved out-of-network treatment was for an urgent medical need that was thought to be concluded or resolved, a new onset of illness or change in your condition requiring further necessary medical services will require a new network exception be granted.
If during the course of your treatment for a condition which was approved for out-of-network care, a new condition or an additional condition requires treatment, a Cone/THN provider will need to be used for that treatment unless there is no such provider within the Cone/THN network. In such an event, a new network exception will need to be requested to determine if an approved out-of-network provider can be used for the newly discovered condition.
Advantages of the Focus Plan
- No deductible if you follow the plan rules for Coordinated Care
- Low premiums
- No cost for e-Visits and Virtual Visits. NOTE: A video visit with your personal physician is considered an office visit.
- No out-of-pocket costs for primary care with Coordinated Care
- Low out-of-pocket predictable costs for all other services with Coordinated Care
Disadvantages of the Focus Plan
- Narrow limited network – not an appropriate plan for those employees who live out of the local area or have dependents out of state or for those currently receiving treatment at a provider or facility not in the network and you want or need to stay with that provider (refer to Important Change for 2021 information in above paragraph)
- Referral process necessary to see a Specialist
- If you see a Specialist, must make sure that the Specialist is in-network AND that you notify Centivo of the referral prior to seeing the Specialist
- Claims are processed as Uncoordinated if you do not follow the plan rules
Focus Plan - Healthy Lifestyle Premiums
New Employees and Employees with a Change in Status
Employees and spouses are required to complete a Health Assessment, on the MyActiveHealth site, within 30 days to keep discounted health premiums. Click here to access the MyActiveHealth site. You will need to Create an Account. If you are covering a spouse on the medical plan, your spouse must also Create an Account and complete.
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Focus Plan Specifics
1. Activate Plan on- line or by phone.
2. Receive referrals for specialty care from your Primary Care Team.
3. Notify Centivo of referrals online or by phone prior to receiving service.
1. No Activation and/or
2. No referrals for specialty care, and/or
3. Do not notify Centivo of referrals prior to receiving service.
Calendar Year Deductible - CYD (Individual/Family): All services subject to deductible except where noted.
Out-of-Pocket Maximum - OOP (Individual/Family)
Preventive Care - Annual wellness exams, Pap test, colonoscopy, bone density and/or vision care (eye exam)
Breast Health - Screening mammograms, ultrasound and/or MRI
Breast Health - Diagnostic mammograms
Breast Health - Diagnostic MRI
Includes both medical and mental health inpatient admissions. All acute inpatient days require pre-authorization.
Outpatient Ambulatory Surgery
Radiology Services - (Except CT, MRI and PET scans) Regardless of where they are done including physician offices
Select Radiology Services - (CT, MRI and PET scans) Regardless of where they are done including physician offices
Primary Care Office Visit - (Includes family practice and internal medicine physicians and pediatricians)
Specialist Office Visit - (Includes all specialty physicians such as surgeons, cardiologists, radiologists, OB/GYNs)
e-Visits via MyChart
Connected Care Virtual Visit (video/phone)
Chiropractic Office Visit
Physician Services - Hospital inpatient or outpatient surgery
Emergency Room Visit
Diagnostic Laboratory Services (Medically necessary)
Therapeutic Services (Physical, occupational, speech therapy office visits)
Cardiac and Pulmonary Rehab Visits
$40 per visit ($1,000 maximum benefit per plan year)
Mental Health Individual Counseling or Group Therapy - Can be self-referred
Focus Plan - Healthy Lifestyle Premiums (26 pay periods)
New employees and status changes, along with covered spouses, are required to complete the Health Assessment within 30 days or premiums will increase by $15.
Full-Time Rates Per Pay Period
Part-Time Rates Per Pay Period
Employee + Child(ren)
Employee + Spouse
Employee + Family
Employee + Spouse w/ Spousal Surcharge
Employee + Family w/ Spousal Surcharge
*Full-time is .75 to 1.0 FTE; Part-time is .30 - .74 FTE.
*Physicians in a profit and loss model will pay total cost of this plan.
*Spouse surcharge of $75 per pay period is required if your covered spouse is offered coverage with another employer and you opt to cover them on a Cone Health medical plan. You do not have to pay the surcharge if your spouse is unemployed, self-employed, retired, on Medicare, a student or also a Cone Health employee.
*Failure to complete the Health Assessment will add $15 per pay period to your health premiums.