Benefits Update

 

 

 

Human Resources

 

2006 Medical Plan Frequently Asked Questions

 

What is the difference between co-payments, coinsurance, and deductibles?

Why is the HMO Only plan coinsurance 20% when the Options Low Deductible plan in-network coinsurance is 10%?

What charges will apply to the out-of-pocket maximum?

Is there a way to find out what services cost so that I can compare the cost of in-network vs. out-of-network services?

After I’ve selected a plan, what information will help me to decide how much to set aside in my health care personal expense account.

Will Group Health Options, Inc. bill me for the deductibles and coinsurance?

Will providers accept payment terms, i.e. spread payments over a period of months?

What if I’m traveling periodically?

I understand that if I use a First Choice Health Network provider for out-of-network services, I will benefit from First Choice network discounts.  How can I find out if the out-of-network doctor or hospital I plan to use is part of the First Choice network?

Can I go directly to a specialist within the designated network provider, Group Health Cooperative, or do I need a referral from a Group Health Cooperative primary care physician?

Does my family member/do my family members have to enroll in the same plan I enroll in? 

I understand that for in-network benefits we need to go to the designated network provider, Group Health Cooperative.  But what if my son/daughter who is in college is living outside of the Group Health Cooperative area?  What if I am on sabbatical outside of the Group Health Cooperative area? 

 Are refrigerated drugs available through the mail order program?  

How does worldwide coverage work?
 

 

The following questions and answers were provided by Group Health.

 

What is the  “Welcome Plan Rider?”

 

How are hospital services covered?

 

Can a member choose to “pay” for a visit rather than have it count towards their four-visit limit?

 

What happens after the member uses all four office visits? What financial obligation does the member have on the 5th and subsequent visits?

 

Does each covered member get four visits per calendar year?

 

Can a member transfer a visit to another member (i.e. Mom uses all four, Dad uses one, can he give his away to another family member)?

 

How are diagnostic lab and x-ray services covered?

 

How much does an x-ray cost? How many can you get for $500?

 

If you use up $500 of lab and x-rays on your first visit, do you get the next visit for your OV copay, plus pay the deductible/coinsurance on the lab and x-rays?

 

Is a member's routine Well Care exam covered under the four-visit benefit?

 

If the patient is treated for a non-well care issue during a Well Care visit, how will this be covered?

 

Are the Welcome plan first four outpatient office visits counted down according to date-of-service?

 

 


 

 

What is the difference between co-payments, coinsurance, and deductibles?

Co-payments

Co-payments are charged and paid at the time you receive certain types of services, such as office visits, prescription drugs, and emergency room services.  These charges do not apply to the out-of-pocket maximum.

Coinsurance

Coinsurance is the percentage of each claim above the deductible that you pay.  If the coinsurance is 20 percent, you pay for the deductible plus 20% of the covered expenses. In this example, after paying 80% of the covered expenses up to a specified maximum, Group Health Options, Inc. starts paying 100% of covered expenses.  The amount you pay will be determined by the plan you select, the type of service you receive, as well as whether the service is received from an in-network or an out-of-network (if applicable) provider.  Out-of-pocket costs for coinsurance usually apply towards a total maximum amount that you are liable for during the year.

Deductibles

The annual deductible is the amount you are responsible for under the health plan before the health plan will begin to pay.  There is a deductible for an individual, as well as for any covered family members.  The most a family will pay in deductibles is limited to three times the individual deductible.

 

 

 

Why is the HMO Only plan coinsurance 20% when the Options Low Deductible plan in-network coinsurance is 10%?

The three plan choices are designed to balance both premium costs and out-of-pocket expenses at the time of service.  Each plan was the result of finding the right mix of benefits needed to achieve premium costs that accomplish the following:

 

 

 

What charges will apply to the out-of-pocket maximum?

Out-of-pocket maximums for in-network and out-of-network services are separate.  Your share of coinsurance expenses applies towards the out-of-pocket maximum.  Co-payments and deductibles do not apply towards the out-of-pocket maximum.

 

 

 

Is there a way to find out what services cost so that I can compare the cost of in-network vs. out-of-network services?

We suggest you contact your health care providers to request their fee schedules for the health care services you routinely seek. 

 

 

 

After I’ve selected a plan, what information will help me to decide how much to set aside in my health care personal expense account.

You (and your family’s) out-of-pocket health care expenses are the result of your use of and the cost for health care services.  In determining the amount to set aside in your health care personal expense account, it is helpful to look at the past year: 

Additionally, in funding your health care personal expense account, you will want to think about possible expenses like those listed below:

 In all cases you will want to contact your providers to obtain an estimate of the cost of these procedures, or look at your past records (Explanation of Benefits from your insurance company) as a possible indicator of your future expenses.

 

 

 

Will Group Health Options, Inc. bill me for the deductibles and coinsurance?

Yes.  Unlike co-payments, deductible and coinsurance payments will not be required at the time you receive services.  You will be billed for deductible and coinsurance payments at a later date.  Group Health Options, Inc. will process the claim and send you an Explanation of Benefits (EOB) that will detail the total charges; Group Health Options, Inc.’s portion; and any amounts that are your responsibility to pay (deductible, coinsurance, and uncovered services).

 

 

 

Will providers accept payment terms, i.e. spread payments over a period of months?

In all cases, you should discuss the costs of medical or dental services and payment requirements with your provider(s) in advance of any high-cost procedure.

 At Group Health Cooperative, the in-network Designated Provider, you have 3 months to pay your claims balance in full. If you need longer to pay, i.e., for an elective surgery or high-cost procedure, you can work with Group Health Cooperative to obtain approval for a longer payment schedule.

 You will need to work with out-of-network providers on an agreeable payment schedule.

 

 

 

What if I’m traveling periodically?

Claims incurred while traveling will be handled differently based on which plan you select.  Emergency services are the only services that that will be covered under the HMO Only plan when you are traveling outside the HMO service area.  Group Health Cooperative is the Defined Network provider for the HMO only plan, so emergency services are the only services that will be covered under the HMO Only plan when you are traveling outside the Group Health Cooperative service area.  For the Options High Deductible and the Options Low Deductible plans, you can seek care from any licensed provider.

 

 

 

 

I understand that if I use a First Choice Health Network provider for out-of-network services, I will benefit from First Choice network discounts.  How can I find out if the out-of-network doctor or hospital I plan to use is part of the First Choice network?

 There is a link to the First Choice Health Network provider directory at http://www.fchn.com/ from the university’s web site.  The link is from the Benefits Information page on the HR web site under Additional Resources.  The link is called First Choice Provider Directory. 

 

 

Can I go directly to a specialist within the designated network provider, Group Health Cooperative, or do I need a referral from a Group Health Cooperative primary care physician? 

Whether you are enrolled in the HMO Only, the Options High Deductible, or the Options Low Deductible plan you can “self-refer,” that is, you can schedule an appointment with a specialist within Group Health Cooperative, without a referral.  Does that include dermatology?  Yes.

 

 

Does my family member/do my family members have to enroll in the same plan I enroll in?  

Yes, all eligible family members have to enroll in the same plan as the faculty/staff member.  

 

 

I understand that for in-network benefits we need to go to the designated network provider, Group Health Cooperative.  But what if my son/daughter who is in college is living outside of the Group Health Cooperative area?  What if I am on sabbatical outside of the Group Health Cooperative area

Group Health Cooperative has a reciprocity agreement with Kaiser Permanente, with locations in other parts of the U.S.  To find Kaiser facilities in other locations, visit http://www.kaiserpermanente.org/, enter the site as “a member,” then go to “locate facilities” and select a region of the country.

 

 

 

 (Question and answer provided by Group Health).

 

What is the  “Welcome Plan Rider ?”

 

 “Welcome Plan Riders” waive member deductible and co-insurance cost share for the first four outpatient visits in any calendar year. Copays for visits still apply.  

 

 

 

 

 

How are hospital services covered?

 

Charges are subject to the annual deductible. Once the deductible is satisfied, then the plan coinsurance is applied. No copay is charged.

 

 

 

 

 

Can a member choose to “pay” for a visit rather than have it count towards their four-visit limit?

 

The Benefit File is set up to count down the visits as they occur. A member will not be able to pick and choose certain visits they want to pay for out of pocket.

 

 

 

 

 

What happens after the member uses all four office visits? What financial obligation does the member have on the 5th and subsequent visits?

 

The member will always be asked to make their copay at the point of service, but in addition, the plan deductible and coinsurance are applied to the visit and will be billed to the patient. The maximum out-of-pocket incurred by a family will not exceed out-of-pocket maximum limit for their plan.

 

 

 

 

 

Does each covered member get four visits per calendar year?

 

Yes, coverage applies to each family member enrolled. Every family member receives four outpatient visits for a copay only. On the fifth and subsequent visits, the plan's copay, deductible and coinsurance are applied.

 

 

 

 

 

Can a member transfer a visit to another member (i.e. Mom uses all four, Dad uses one, can he give his away to another family member)?

 

No. The first four visits cannot be swapped or shared.

 

 

 

 

 

How are diagnostic lab and x-ray services covered?

 

Under the Welcome plans, a $500 allowance applies to diagnostic lab and x-ray services (this includes mammograms). Once the member has exhausted the $500 allowance, then the member pays the applicable deductible and coinsurance on lab and x-ray services. If the member's lab/x-ray service exceeds the $500 allowance, then the member will be obligated to pay the deductible on the balance and coinsurance on any amount remaining after the deductible is satisfied.

 

 

 

 

 

How much does an x-ray cost? How many can you get for $500?

 

Some diagnostic x-ray or scans can cost over $500. If the lab and x-ray charges exceed $500, then the member will be billed the balance, which is subject to the deductible and coinsurance.

 

 

 

 

 

If you use up $500 of lab and x-rays on your first visit, do you get the next visit for your OV copay, plus pay the deductible/coinsurance on the lab and x-rays?

 

Yes, if you haven't used all four of your outpatient office visits yet.

 

 

 

 

 

Is a member's routine Well Care exam covered under the four-visit benefit?

 

Yes, one of the first four visits can be applied to a Well Care exam, when in accordance with the well-care schedule established by GHC. On the 5 th or subsequent Well Care outpatient visit, the member pays a copay and coinsurance on the billed charges (not subject to the deductible).

 

 

 

 

 

If the patient is treated for a non-well care issue during a Well Care visit, how will this be covered?

 

Services provided during a preventive care visit, which are not in accordance with the well care schedule, are covered subject to the applicable outpatient services cost-shares.

 

 

 

 

 

Are the Welcome plan first four outpatient office visits counted down according to date-of-service?

 

No, The visits are counted down by which ones hit the claims system first. In other words, if a members has two visits a few days apart, there is a chance the last visit might clear the claims system before the first visit. If the above scenario happens, then the member may appeal the claim to have the order reversed (this would be if the member has an expensive claim that processed as the fifth and not the fourth claim).

 

 

 

 (Question and answer provided by Group Health).

 

 

 

 

 

 

 

Are refrigerated drugs available through the mail order program?  

Yes, the prescriptions are mailed in special packaging that maintains the required temperature.  Visit http://www.ghc.org/pharmacy/mailorder.jhtml for more information.

 

 

How does worldwide coverage work?

If you are enrolled in the HMO Only plan and are traveling out of the Designated Network Provider (Group Health Cooperative) area, you are covered for emergency care only.  If you are enrolled in the Options High Deductible or the Options Low Deductible plan, you can utilize out-of-network benefits world-wide.  However, you may be required to pay the entire bill and then submit it to Group Health Options, Inc., for reimbursement when you return home.