A PREMIUM is the amount you pay for insurance, using pre-tax or post-tax dollars. 

A DEDUCTIBLE is the amount of money you are responsible for paying each year before the plan begins to pay for covered services. Your plans include two types of deductibles:

Embedded Deductible: One individual must meet the single deductible.  A combination of 2 or more members can meet a family deductible.

COINSURANCE This is your share of the expense of covered services after your deductible has been paid when the company plan is paying a percentage. The coinsurance rate is usually a percentage.

OUT-OF-POCKET (OOP) MAXIMUM is the most you pay per Plan Year for health care expenses and applies to deductibles, flat-dollar copays and coinsurance for all covered services – including cost-sharing amounts for prescription drugs. Once this limit is met, the plan will cover all in-network services at 100% until the end of the plan year.

OUT-OF-NETWORK charges are subject to reasonable and customary limitations, which means you are responsible for any charges that exceed the carrier’s contracted amount (often referred to as balance billing). In addition, charges will be paid at the non-network deductible and coinsurance. Call your insurance carrier or refer to your provider’s network directory to verify if the provider is in network – this includes all providers of care: radiologists, pathologist or any referrals from physicians. 

PPO HSA | In-Network & Out-of-Network Benefits

The HDHP is similar to the PPO Plan in that you have the option to choose any provider when you need care. However, in exchange for a lower per-paycheck cost, you must satisfy a higher deductible that applies to almost all health care expenses, including those for prescription drugs.

All expenses are your responsibility until the deductible is reached, with the exception of preventive care, which is covered at 100% when you visit a physician in the network. Once the deductible is met, you are responsible for coinsurance for medical expenses and a copay for prescription drug expenses.

Enrolling in this plan allows you to contribute tax free dollars to a health savings account (HSA). Any dollars that you (and your employer) wish to contribute can be used towards any eligible medical, Rx, dental and vision expenses that you may incur while covered under the plan. See HSA section of this guide for additional details.

PPO | In-Network & Out-of-Network Benefits Available

The PPO option offers the freedom to see any provider when you need care. When you use providers from within the PPO network, you receive benefits at the discounted network cost. Most expenses, such as office visits, emergency room and prescription drugs are covered by a copay. Other expenses are subject to a deductible and coinsurance.

Preventive Services | Covered at 100% NO COST SHARE

All plans recognize routine preventive services at 100%, no coinsurance, no deductible as long as the claim is submitted as “routine or preventive” and the services performed falls within the approves list of preventive services. For a complete and updated listing, please go online and search uspstf-a-and-b recommendations or visit https://www.uspreventiveservicestaskforce.org.

During your wellness visit, proactively let your physician know the reason for the appointment is for a wellness visit and that your physician needs to submit and code the visit as routine, preventive in nature. If your visit is submitted with a diagnosis, the wellness visit will not be paid at 100%, but instead, will be subject to deductible and coinsurance.  Below are a few examples of services that can be recognized as preventive:

• Routine Wellness Exams, including well baby & child routine exams
• Cholesterol and lipid level screening
• Pelvic exam, pap test and screening mammograms
• Colorectal cancer screening, colonoscopies, sigmoidoscopies (age limit applies)
• Vaccines & immunizations: Hepatitis A & B, Influenza, Pneumonia, Shingles
• Contraceptives (specific list applies) & Diabetes screenings