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FAQs for Members

How Your Health Plan WorksHealthcare TermsPrimary CareFinding CareWhat's CoveredClaimsPrescriptionsAppAncillary Benefits

Your Poppins Health Plan and How it Works

What makes my plan with Poppins Health different from other health plans?

Poppins Health is different in a few ways. It starts with primary care.

With a Poppins plan, you have the option to get unlimited access to new primary care models, which include services such as behavioral health and chronic care support. You can choose to not use one of these plans, called the Advanced Primary Care plans.

We also got rid of deductibles and coinsurance, so you just have to worry about copays. This means no more confusing math. Health insurance has been too complicated, so we're trying to remove the unnecessarily confusing components. And, your monthly premiums cost less.

Still have questions? Send us a message in your app (members.poppinshealth.com) or call us at 1-888-807-2381.

How much will it cost me for visits with providers, hospital stays, labs, etc.?

If you are on one of our Advanced Primary Care plans, your primary care is completely free. If you are on our Traditional plan, your primary care copays may vary - reach out to us and we can help you in better understanding this. For any non-primary care services or visits, our Member Navigation team can help you find high value, low cost care. We have many $0 options.

If you get care without reaching out to us first, you might end up going to a higher cost provider. Check your plan documents for the range of costs for services or each out to us - we're always happy to help.

What is my deductible?

$0 – We don't have deductibles! This is typically the amount you have to pay before your coverage kicks in and the plan starts to share the burden of healthcare costs with you. But you don't have to worry about this. The good news is that we start sharing in costs immediately.

What is my coinsurance?

We don't have coinsurance! We found that the math and the concept can be confusing, so we got rid of it.

What is my out-of-pocket maximum (OOPM)?

This is the most you'll pay for covered healthcare services in a year. You have two different out-of-pocket maxiums (OOPMs) - one for Tier 1, 2, 3 services and one for Tier 4, 5 services.

If you have any dependents on your plan, you have both individual and family out-of-pocket maximums. In this case, all of the individual OOPMs count towards the family OOPM.

For example: Scarlett, John and Timothy are on a plan and they have an individual OOPM of $7,000 and a family OOPM of $14,000. Let's say that Scarlett has received care totaling $4,000 in copays, John has received care totaling $6,000 in copays, and Timothy has received care totaling $4,000 in copays. In this case, no one has hit the individual OOPM, but they have collectively hit the family OOPM (because 4,000 + 6,000 + 4,000 = 14,000). So, for any other care that someone in this family gets in this year, they won't pay anything because they have hit their OOPM.

See your plan documents or contact us via message in your app, members.poppinshealth.com, or by phone, 1-888-807-2381, if you have questions.

How do I start using my new plan?

Once you enroll, we will send you your welcome materials. You can start seeing providers as soon as your plan starts. If you enroll less than two weeks (14 days) before the date your coverage starts, you may not yet have your ID card in the mail by the day that your plan starts. If you have any questions, you can contact us via message in your app, members.poppinshealth.com, or by phone, 1-888-807-2381.

How does coverage work for dependents under 18 years old?

If you are on the Advanced Primary Care - Virtual plan, then you have Firefly Health as your primary care provider. Firefly does not see any patients who are under 18, so if you have a child or children under 18, then they can see a normal pediatrician. Let us know if we can help you find one.

For anyone on the Traditional or Advanced Primary Care - In Person plans, your coverage is the same for everyone regardless of age.

How do I reach out to the Poppins Health team?

Send us a message via your app, members.poppinshealth.com, or call us at 1-888-807-2381. Our Member Navigation team is here to help you with any questions you might have. Our hours are Monday - Friday from 8am - 6pm ET, and Saturday from 8am - 12pm ET. If you message or call us outside of these hours, we'll get back to you as soon as we're back.

How do I add a spouse/partner or dependent to my plan?

Reach out to your employer to let them know you need to add a new dependent to the plan via a Qualifying Life Event (QLE).

How will I get updates from Poppins about my plan?

We will reach out to you over the course of the year if there are any messages or other plan updates that need your attention.

Healthcare Terms

What is a copay?

A copay is the amount you owe for some healthcare services. It's a flat fee that varies by service, such as $400 for an emergency room visit or $20 for a specialist visit. Please note that this is an example - check your plan documents or reach out to us to know your actual copays.

What is a primary care provider (PCP)?

These providers are a great first point of contact for any non-emergent questions or concerns you might have about your health. They may refer you to another provider, such as a specialist, for follow up on certain conditions, but we always recommend checking in with your PCP first if you're not totally sure what's going on or what care you need. A primary care provider is also often known as an internal medicine provider, general practitioner, or family doctor. They are also referred to as a "PCP."

What is the difference between a doctor, a provider, and physician?

You can think of these all as the same. They're generally used interchangeably.

What is advanced primary care (APC)?

Advanced primary care (APC) is a newer model of primary care. In this model, you still see a primary care provider and benefit from the value of having a consistent provider who knows who you are and can help coordinate your care. It's just paid for differently. These doctors get paid a monthly subscription fee, instead of a per visit fee. This way, they're incented to keep you healthy and you don't need to limit your interaction with them because of cost.

The great news is that we cover the subscription fee for all of our members so that this offering is $0 for you. That's right - unlimited, free primary care!

Please note: if you are on the Poppins Health Traditional plan, you have chosen to not use an APC provider and thus don't have unlimited, free primary care. If you are on the Traditional plan and don't have a PCP, reach out to us via message in your app, members.poppinshealth.com, or by phone, 1-888-807-2381, and we can help you find a great option.

What is a specialist?

A specialist is a provider who concentrates in a specific field of medicine. For example: a dermatologist specializes in conditions involving the skin, hair and nails; a cardiologist specializes in treating heart conditions. There are many more!

What is a Qualifying Life Event (QLE)?

A Qualifying Life Event (QLE) is a major life change that may allow you to make changes to your benefit selections. Some examples of a qualifying life event would be a change in marital status or a change in number of dependents. For a full list of QLEs, see this link: https://www.healthcare.gov/glossary/qualifying-life-event/.

What is Reference-Based Pricing (RBP)?

Reference-Based Pricing (RBP) is the term for how we reimburse providers, and using it means that you end up paying a fair price for the care you receive. We use publicly available cost data and determine reimbursement amounts off of that transparent data. If you have more questions about RBP, reach out to our Member Navigation team via message in your app, members.poppinshealth.com, or by phone, 1-888-807-2381.

Primary Care

How do I know which primary care provider I selected?

You can see this information in the app, members.poppinshealth.com, under the "Plan Details" or "Get Care" pages. If you have any questions, send us a message in your app or call us at 1-888-807-2381.

If I selected Firefly Health or Marathon Health for primary care, am I not allowed to see other primary care providers?

You can absolutely see any provider you want, we're not stopping you! We did partner with Firefly Health and Marathon Health because we think they provide a superior primary care experience. If you are on one of the Advanced Primary Care plans, and you want to see a traditional primary care provider, then your copays for primary care visits start at $100.

Finding Care

What is the difference between emergency care and urgent care?

Emergency care is meant for true medical emergencies and life-threatening situations. If you are experiencing this, please dial 911 and go to your nearest emergency room.

An urgent care facility handles non-life-threatening situations. Urgent care are typically open late and on weekends, and often have onsite access to labs and x-rays.

Will I have to call Poppins Health or my doctor if I go to an urgent care center or to the emergency room?

If your condition is an emergency, please call 911 and go to the nearest emergency room. Your copay is the same no matter where you go.

If your condition isn't life threatening or otherwise emergent, you have two options: your primary care provider or an urgent care center. Your primary care provider is best positioned to help you. If you need to go to an urgent care facility, your copay may vary depending on where you go. We can help find you a high quality, low cost urgent care center.

How do I find an emergency room or urgent care center close to me?

Reach out to us, we can help you! You can send us a message in your app at members.poppinshealth.com or call us at
1-888-807-2381.

How do I keep seeing the providers I know and like?

Let us know about them! We continue to add partnerships with providers on a regular basis, and the best ones are with providers who our members see and love. You can give us a call at 1-888-807-2381 or submit your provider's information in our "Add a Provider" form in your app at members.poppinshealth.com.

How do I find a doctor who accepts Poppins Health insurance?

Reach out to our Member Navigation team and we can help you with this. You can send a message via your app, members.poppinshealth.com, or call us at 1-888-807-2381.

Do I need to get a referral to see a specialist?

No, but if you reach out to us we can help make sure that you're going to a specialist that is high quality and low cost. If you are on one of the Advanced Primary Care plans, your primary care provider will have great specialist suggestions as well.

What happens if I don't reach out to Poppins before seeing a provider?

That's fine! You can see the range of prices for visits in your plan documents. We are here to help you if you want to ensure that you'll be able to see a great doctor at the lowest cost. If you see a provider without contacting us or your advanced primary care provider first, you may end up paying more than if we had helped you find care.

Do I need prior-authorization?

Prior-authorization is needed for some services. This means that your plan must approve the service before they will pay for it. We only have this for higher cost services, such as surgeries or MRIs. You can see the list of services that require prior-authorization in your plan documents. You can also reach out to us via message in your app, members.poppinshealth.com, or phone, 1-888-807-2381, and we can walk you through this.

What should I do if my provider asks me what my copay is?

If you reached out to us before your visit, you can share with them the copay amount we told you. If you didn't reach out to us beforehand, no problem, just have them call us at 1-888-807-2381 and we can let them know what the copay should be.

What should I do if my provider is saying I owe more than the copay that a Poppins Health Navigator told me?

Have your provider call us at 1-888-807-2381 and we can let them know what the copay should be. This is the same number that is on the back of your ID card.

Why do I need to reach out to you to get copay amounts and find providers?

Good question! Our provider network is based on a lot of research that looks at the clinical quality of a provider and facility, the relative cost, and experience data. We want to send you to the best providers, and that doesn't always mean the highest cost providers. No need to google for where to go - just come to us and we can direct you.

What's Covered

Is COVID-19 testing covered by my plan?

Yes. See your plan documents or reach out to us for details.

What vaccines are covered by my plan?

Preventative care immunization range from $0 to $150. See your plan documents in the Plan Details section of your app or reach out to us and we can help direct you to lower costs options.

Is behavioral or mental health covered by my plan?

Yes! We think behavioral and mental are critical parts of your healthcare. If you're on an advanced primary care (APC) plan, you have access to these services through those partners - at no cost to you. For members on the Traditional plan or if you want a behavioral health provider not affiliated with our APC partners, that's great too. Reach out to us and we can help you find a great provider.

Are fertility and family building benefits covered by my plan?

We offer fertility benefits only if your employer has opted to offer them. Read your plan documents in the Plan Details section of your app for more information, or reach out to us and we can help you understand if you have these benefits and what these look like.

Is acupuncture covered by my plan?

We offer fertility benefits only if your employer has opted to offer them. Read your plan documents in the Plan Details section of your app for more information, or reach out to us and we can help you understand if you have these benefits and what these look like.

Is chiropractic work covered by my plan?

Yes, we cover up to 20 visits per person per year. See your plan documents.

Is massage therapy covered by my plan?

Not right now, but we're working on making this an included benefit for future plans.

I'm planning to travel internationally - will I be covered?

Only urgent or emergency medical care is covered while traveling outside of the United States. Non-urgent or non-emergent medical treatment received outside of the United States is not covered.

Claims

What is an explanation of benefits (EOB)?

This is a statement from Poppins that outlines what your provider billed and what was covered by the plan.

Can you help me understand a bill I received where my provider says I owe money?

Sometimes, your provider won't accept what we pay them and will send a bill directly to you. This isn't uncommon, but we know it's a headache. We can help you with this and engage with the provider on your behalf, but we won't know that you got this bill unless you let us know about it. You can go to your app and send us the bill using the Submit a Bill feature. Send it over and we'll take care of it for you, keeping you updated along the way.

How do I check the status of a claim?

You can see the status of your claim in your app under the Activity section. Or you can reach out to us and someone on our Member Navigation team will help you.

How do I submit an appeal?

If you believe that a claim has been denied incorrectly, either in part or in full, you can submit a written appeal.

The appeal must include:
1. The full name of the member who received the care or medication
2. The member's social security number
3. The group ID (see the front of your ID card for this)
4. A statement that outlines what you disagree with, and the reason why you're disagree
5. Any further context on why you're submitting the appeal

To submit your appeal: 
Email your appeal to:
appeals@poppinshealth.com

OR 

Mail your appeal to:
Poppins Health Corporation
2093 Philadelphia Pike #7677
Claymont, DE 19073

Prescriptions

What pharmacies should I go to?

We use a partner called CapitalRx for your prescription drug benefits. Capital Rx maintains a national network of more than 60,000 pharmacies, including all national chains and most independent pharmacies. However, with some prescription benefit plans, certain pharmacies may be excluded from the network. To confirm coverage at a specific pharmacy, feel free to contact our Member Navigation team via message in your app, members.poppinshealth.com, or call us at 1-888-807-2381.

You can also reach out to CapitalRx directly at 1-888-832-2779.

How do I find out if a medication is covered by my plan or what the medication will cost?

Your coverage for each prescription drug is outlined on our formulary in your Plan Documents. We use a standard formulary that provides coverage for the majority of common prescription drugs on the market. These details are in your plan documents. If you have more questions, contact our Member Navigation team via message in your app, members.poppinshealth.com, or call us at 1-888-807-2381.

You can also reach out to our pharmacy partner, CapitalRx, directly at 1-888-832-2779.

How do I get my medications via mail order?

Message us in your app, members.poppinshealth.com, or call us at 1-888-807-2381 for details on mail-order prescriptions.

You can also reach out to our pharmacy partner, CapitalRx, directly at 1-888-832-2779. Mail order medications can be delivered directly to your doorstep instead of being picking them up at a pharmacy.

How can I save money on my medications?

Let us help you! We can see if you're able to access your prescriptions at a lower cost. Feel free to contact our Member Navigation team for help. You can send us a message in your app, members.poppinshealth.com, or call us at 1-888-807-2381.

You can also reach out to our pharmacy partner, CapitalRx, directly at 1-888-832-2779.

Poppins Health App

How do I activate or log into the Poppins Health app?

Go to members.poppinshealth.com and log in from there. If you have never logged in before, you'll need to activate your account. If you are a dependent of the plan, have your primary plan holder send you an invite directly from the app.

Do I need to use the Poppins Health app?

No! You don't have to use the app. However, we did build it so that you could have important information at your fingertips and have a way to communicate with our team easily and send us important information like providers you want to see and bills you want us to take a look at. We encourage you to use the app if you're able.

Why can’t I find the Poppins Health app on the App Store or Google Play?

Good question! We decided to build the app so that it can be on your desktop and your phone, and that means that it's accessible through browser link instead of needing to download it.

Ancillary Benefits

How do I find a dentist?

Unfortunately, Dental benefits are not currently part of Medical insurance. We think it’s crazy, too, and we’re working on it. In the meantime, check with your employer to see what Dental partner they selected for your Dental benefits.

How do I find an eye doctor?

Unfortunately, Vision benefits are not currently part of Medical insurance. We think it’s crazy, too, and we’re working on it. In the meantime, check with your employer to see what Vision partner they selected for your Vision benefits.