Medical benefits

What is a deductible?

A deductible is the amount of money that members pay out of their own pocket before the plan begins to pay benefits.

What does the term “coinsurance” mean?

Coinsurance enables members to split their eligible healthcare costs with the insurance carrier. It is the percentage of the cost of healthcare services that members pay. For example, if a health plan has an 80/20 in-network coinsurance rate for specific services, after the deductible has been satisfied, the insurance company is then responsible for 80 percent of the eligible charges and the member is responsible for the balance (out-of-network coinsurance levels will differ from in-network coinsurance levels). Once members reach their plan- year out-of-pocket maximum, the insurance carrier will pay for 100 percent of the eligible expenses (subject to plan limitations).

Do all expenses apply to a member’s medical maximum out-of-pocket cost?

No. Expenses applied toward the annual deductible do not apply toward the out-of-pocket maximum (except for Plan 9). Fixed-dollar copayments and disallowed charges do not apply toward the annual deductible or out-of-pocket maximum. Please note that the Rx program out-of-pocket works differently; for more information please refer to the Pharmacy FAQ.

Members are required to pay for the following costs. They do not accrue toward members’ out-of-pocket maximum, and members must pay for them even after their out-of-pocket maximum is met.

If a member is on a plan that requires some medical copayments, does the deductible need to be met before the services with copayments are paid?

Services with copayments such as office visits and outpatient rehab therapy visits are paid without the deductible needing to be met. The member is only responsible for the copayment and ODS pays the rest.

Services such as emergency room visits, imaging procedures, sleep studies, upper endoscopy, spinal injections and additional cost-tier procedures require the member to pay the copayment, then the annual deductible and then benefits will pay at the appropriate coinsurance level.  

Does the deductible for in- and out-of-network commingle (meaning that there is one deductible for both in- and out-of-network services combined)?

Yes.

Does the out-of-pocket maximum for in- and out-of-network service commingle?

With Plans 3 through 8, services accumulated toward the in-network out-of-pocket maximum can be used to satisfy both the in- and out-of-network out-of-pocket maximum. However, services accumulated toward the out-of-network out-of-pocket maximum cannot be used to satisfy the in-network, out-of-pocket maximum.

Plan 9, a Health Savings Account (HSA)–compliant plan, services accumulated toward both the in- and out-of-network out-of-pocket maximums can be used to satisfy both the in- and out-of-network out-of-pocket maximums.

What are members’ benefits while traveling?

Beginning October 1, 2011 members have access to the ODS Travel Network. The Travel Network allows medical plan members to receive emergency and nonemergency care outside of their primary service area while traveling. Eligible members need to seek care from a PHCS “Healthy Directions” provider, and will receive in-network benefits.  Dependents living outside of the primary network area can also use the ODS Travel Network to receive care at an in-network benefit level. The ODS Travel Network is not an alternative primary network. Members must seek in-network services whenever possible, and preauthorization is required for in-patient services.

If a member is traveling out of the service area and seeks care from an out-of-network physician or provider, the benefit will be paid at the out-of-network benefit level. Out-of-network benefits are subject to the maximum plan allowable.  

What is the “maximum plan allowable”?

Maximum Plan Allowable (MPA) is the maximum amount that ODS will reimburse physicians and providers. For an in-network physician or provider, the maximum amount is the amount the provider has agreed to accept for a particular service.

ODS will process charges for services by an out-of-network physician or provider as follows: the maximum amount is the lesser of the amount payable under any supplemental provider fee arrangements ODS may have in place and the 75th percentile of fees commonly charged for a given procedure in a given area, based on a national database.

ODS will process charges for services by out-of-network facilities as follows: the maximum amount is the lesser of supplemental facility arrangements ODS may have in place, 125 percent of the Medicare Allowable Amount based on data collected from the Centers for Medicare and Medicaid Services (CMS) or the billed charge. The 125 percent Medicare Allowable Amount does not apply to emergency services.

In each of the above situations relating to an out-of-network physician , provider or facility, any amount above the MPA is the member’s responsibility.

What if a member is out of the service area and has a medical emergency?

If a member is out of the service area and has a medical emergency, the member should go to the nearest emergency room. Benefits will be paid at the in-network benefit level, subject to the maximum plan allowable for emergency services.  

If a member has a specific rare condition and needs to continue to see a provider that is not in the network, will ODS pay at the in-network benefit level?

ODS will follow its standard Transition of Care healthcare services policy. Transition of Care services may be approved under extraordinary circumstances for a finite period of time for a member who, while actively receiving medically necessary services, moves from a health plan with another carrier to ODS and, as a result, the ongoing medical services become out of network. The member must complete a Transition of Care form that ODS will review and approve.

How does medical Plan 9, the HSA–compliant plan, work?

Health Savings Account–compliant plans give consumers incentives to manage their own healthcare costs by coupling a tax-favored savings account used to pay medical expenses with a high-deductible health plan (HDHP) that meets certain requirements for deductibles and out-of-pocket expense limits. HDHPs cover preventive care services (e.g., routine medical exams, immunizations and well-baby visits) without requiring the enrollee to first meet the deductible. OEBB Plan 9 is a HSA–compliant plan.

This plan has a high deductible that must be met prior to any benefits being paid out (except for specific preventive services when performed by in-network providers). It is important to understand that the family deductible is an aggregate deductible. Therefore, for any subscriber enrolled with one or more dependents on the plan, the entire family deductible must be satisfied before benefits are payable for services subject to the deductible (basically everything, including prescriptions, except preventive services). This is different from how the deductibles work on the other plans, where each individual can separately meet a deductible. Please note: IRS regulations may prohibit coordination of benefits in order to receive HSA benefits tax-free.

What is the new incentive tier?

On Plans 3 through 6, members will pay a lower office visit copay for visits to manage certain conditions. These conditions include:

What is the Additional Cost Tier?

The Additional Cost Tier refers to select procedures including:

Members are encouraged to start a dialogue with their provider and to explore less invasive treatment alternatives if possible. There is a $500 copayment for Additional Cost Tier procedures on Plans 3 through 8, plus the applicable deductible and coinsurance. Effective October 1, 2011 upper endoscopies and spinal injections are subject to a lower, $100 copayment. 

Alternative care is listed on the benefit summaries as a coinsurance amount; however, it also indicates that “services will be covered the same as any other benefit would be under the plan up to the combined benefit maximum.” Plans 3 through 5 have an office visit copayment. Does this copayment also apply to alternative care providers?

Yes. If a member seeks services from an alternative care provider, benefits are reimbursed just like any other service up to the combined maximum of $2,000 per plan year. Therefore, office visits on Plans 3 through 5 would be subject to the primary care copayment, in lieu of the coinsurance amounts. Lab fees would be subject to the applicable plan coinsurance amount. Providers will need to obtain service authorization with ODS for alternative care services beyond the 12th visit.

What disease management programs does ODS offer?

ODS offers the following health coaching programs:

To enroll, call an ODS health coach at 800-913-4957 or 503-243-3957

What are the benefits for weight management?

Benefits for weight management include one obesity screening and risk assessment per plan year, ODS health coaching, online educational resources and Weight Watchers support.

Weight Watchers will be a covered value-added benefit, limited to the program’s monthly fee only.

Are midwives and birthing centers covered?

Yes. Effective June 1, 2010, ODS began covering certified nurse midwives and birthing centers.

What benefits are covered under the cardiovascular screening preventive care benefit?

When members go for their yearly physical, the preventive care benefit also includes an EKG and treadmill test.

What benefits are covered under the hearing evaluation preventive care benefit?

This benefit is for children and adults. A brief hearing evaluation during a well-child examination is eligible for benefits. An adult hearing evaluation is covered when performed in conjunction with an adult periodic exam. Effective October 1, 2011 a hearing exam is covered for all medical members.  

Are midwives and birthing centers covered?

Yes. Effective June 1, 2010, ODS began covering certified nurse midwives and birthing centers.

What are my benefits for hearing aids under state mandate?

The plan covers one hearing aid per hearing-impaired ear for members under age 26. This benefit is subject to a 48-month maximum, which will be adjusted annually as required by Oregon statute. A member must be examined by a physician before obtaining a hearing aid that is prescribed, fitted and dispensed by a licensed audiologist. Effective October 1, 2011 this benefit has been extended to all members covered under the medical plan. 

Covered benefits include the following up to the $4,100 dollar maximum every 48 months:

What is a cost containment penalty?

All inpatient services, partial hospitalization, residential stays and some outpatient procedures and prescription drugs require providers to get a pre-service authorization from ODS before performing the procedure. If a member fails to obtain prior authorization when authorization is required (other than specified imaging procedures), a penalty of 50 percent up to a maximum deduction of $2,500 per occurrence will be applied to covered charges before regular plan benefits are computed. The member will be responsible for any charges not covered because of noncompliance with authorization requirements.

The prior authorization penalty does not apply toward the plan’s deductible or out-of-pocket maximum. The penalty will not apply in the case of an emergency admission.

Coordination of benefits is confusing. Can you provide some examples for dual coverage with medical plans so I can get a better understanding of how benefits will be coordinated?

In most cases, once the deductibles and out-of-pocket maximums are satisfied, members will not have any further out-of-pocket costs, unless limitations or maximums are required. If members seek services from out-of-network providers, they will be responsible for any charges in excess of the ODS maximum plan allowance (MPA). If a member has secondary coverage through a non-ODS plan, he or she should check with that plan’s insurance carrier on how it handles coordination of benefits. Please see below for sample scenarios.

Medical coordination of benefit examples:

All examples assume use of in-network providers.

All examples assume use of in-network providers.

Example #1

A claim for knee replacement comes in for a member on Plan 5 primary and Plan 6 secondary. Assuming the billed amount and allowed amount is $5,000, the claim would be processed as follows.

The knee replacement is in the Additional Cost Tier with a $500 copay. This comes out first, then the annual deductible is applied. Once the deductible is met, ODS pays 80 percent of the remainder and the member pay 20 percent.

Claim amount: $5000

Plan 5 payment:
$500 copay applied to Additional Cost Tier
$300 is applied to deductible on plan 5. The deductible is now met.
ODS pays 80% on the remaining $4,200. Total payment under plan 5 is $3,360.

Plan 6 payment:
$500 copay applied to Additional Cost Tier on plan 6.
$400 is applied to deductible on plan 6.
ODS pays up to 80% on the remaining $4,100. Total payment under plan 6 would be $3,280 but since ODS will not pay over the $5000 allowed amount, the actual payment is $1,640.

Total that the member is responsible for paying is $0.

Example #2

Claim 1:
A claim for an MRI comes in for a member on Plan 8 primary and Plan 6 secondary. Assuming the billed amount and allowed amount is $1,000, the claim would be processed as follows. The MRI has an additional copay of $100. This comes out first, then the annual deductible is applied. Once the deductible is met, ODS pays 80 percent of the remainder and members pay 20 percent.

Claim amount: $1000
Plan 8 payment:
$100 copay applied to MRI.
$900 is applied to deductible on plan 8.

Plan 6 payment:
$100 copay applied to MRI.
$400 is applied to deductible on plan 6. The deductible is now met.

ODS pays up to 80% on the remaining $500. Total payment under plan 6 is $400.

Total that the member is responsible for paying is $600.

Claim 2:
A claim for a specialist office visit comes in for $200. The claim would be processed as follows. $900 has already been applied to the deductible on plan 8 and the plan 6 deductible has been met. Once the deductible is met, ODS pays 80 percent of the remainder and members pay 20 percent.

Claim amount: $200

Plan 8 payment:
$100 is applied to deductible on plan 8. The deductible is now met.
ODS pays 80% on the remaining $100. Total payment under plan 8 is $80.

Plan 6 payment:
Plan 6 deductible has been met, ODS pays up to 80% on the $200 charge. Total payment under plan 6 would be $160 but since ODS will not pay over the $200 allowed amount, the actual payment is $120.

Total that the member is responsible for paying is $0.

Example #3

Claim 1:
A claim for a primary care office visit in for a member on Plan 7 primary and Plan 5 secondary. Assuming the billed amount and allowed amount is $140, the claim would be processed as follows. For a primary care office visit, once the deductible is met on plan 7, ODS pays 80 percent of the remainder and members pay 20 percent. Plan 5 has a $25 copay for the office visit and the deductible is waived.

Claim amount: $140

Plan 7 payment:
$140 is applied to deductible on plan 7.

Plan 5 payment:
$0 is applied to deductible on plan 5 since the deductible is waived on primary care visits.
$25 member copay. ODS pays the remaining $115.

Total that the member is responsible for paying is $25.

Claim 2:
A claim comes in for minor office surgery. Assuming the billed amount and allowed amount is $600, the claim would be processed as follows. Once the deductible is met, ODS pays 80 percent of the remainder and members pay 20 percent.

Claim amount: $600

Plan 7 payment:
$360 is applied to deductible on plan 7. The deductible is now met.
ODS pays 80% on the remaining $240. Total payment under plan 7 is $192.

Plan 5 payment:
$300 is applied to deductible on plan 5. The deductible is now met.
ODS pays 80% on the remaining $300. Total payment under plan 7 is $240.

Total that the member is responsible for paying is $168.

What are the different ways to enroll in the tobacco cessation program?

An OEBB member can enroll by:

The standard medical plan will cover tobacco cessation services. This benefit is subject to the plan’s deductible and copayment. However, if members use our exclusive tobacco cessation program, telephone coaching, counseling and supplies are paid at 100 percent with the deductible waived.

Is a physician referral to the tobacco cessation program necessary?

No. Members can self-refer.

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