| Questions and Answers on 2010 Plans |
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| Choice of 2010 Healthcare Plans |
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| Q |
What medical plans will be available for 2010?
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| A |
PEBB will offer three medical plans for 2010.
- PEBB’s Statewide Plan will be available for members throughout the state.
- The Kaiser Permanente HMO will available to members who live (or work at least 50 percent of the time) in the Kaiser service area
- The Providence Choice plan will be available to members who live or work in the Portland metro area (Clackamas, Multnomah, Washington, Yamhill counties).
The Board will continue to offer a version of each plan as an additional option for eligible part-time employees and retirees.
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| Q |
How will PEBB’s Statewide Plan differ from the current plan with Regence?
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| A |
The main difference is in who acts as the insurer – who pays the difference if claims are higher than premiums and who keeps the balance if claims are lower than premiums. Regence insures the current plan. Beginning 2010, PEBB will self-insure the plan. If claims are higher than premiums, PEBB reserves will cover the difference. If claims are lower than premiums, the balance stays in the reserves.
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| Q |
How does Providence Health Plans figure into PEBB’s Statewide Plan?
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| A |
Providence Health Plans will administer PEBB’s Statewide Plan. This means they will contract with a network of doctors, clinics, hospitals and other healthcare providers and will process claims. The network will provide worldwide access. They will administer the plan according to requirements of the contract with PEBB. See the Web site for PEBB’s Statewide Plan.
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| Q |
Why did the Board choose Providence Health Plans to administer the Statewide Plan instead of Regence?
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| A |
They offered the better overall solution for PEBB members in terms of cost, administrative capabilities and responsiveness to the Board’s Vision for healthcare.
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| Q |
What's the difference between PEBB's Statewide Plan and Providence Choice? |
| A |
The Statewide plan is a participating provider organization (PPO) plan. This plan design encourages members to use in-network providers who have a contract with the plan to offer the services covered in the plan at the contract rate. This encouragement takes the form of lower member coinsurance when they see an in-network provider.
Providence Choice is a medical-home-model plan. This plan design encourages members to receive care from a team of providers in their medical home who work together to coordinate care for the member. This encouragement takes the form of low, set co-pays when the member gets care through the medical home.
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| Q |
Why won’t the Kaiser Permanente Added Choice plan be available next year?
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| A |
The Board offered this plan as a way to offer additional choice to members. In this plan, you have lower costs when you access care through the Kaiser system, but you can choose to use another provider if you’re willing to pay more. Initially, 424 members enrolled; total enrollment grew to 611 over four years. With this low enrollment, the Board decided to discontinue the Added Choice plan in 2010. This offers administrative savings for the PEBB program. Members in the Kaiser service area (pdf) continue to have a choice of plans.
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| Coverage and Plan Design |
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| Q |
Will my coverage change in 2010?
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| A |
The Board has made no changes to the current design of the healthcare plans. It is the Board, not the insurance company or administrator, that determines what is covered and at what level in the healthcare plans. Review comparisons of the 2010 and 2009 plan designs.
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| Q |
Where can I see the plan designs for 2010?
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| A |
Review a summary of the medical plan designs. |
| Q |
Will the rural subsidy continue for the Statewide Plan in 2010?
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| A |
Yes. This means that members in the designated rural counties will continue to be responsible only for in-network coinsurance rates when they see providers who are not in the network. See this discussion to understand how the rural subsidy works.
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| Q |
What happens if I’m getting treatment outside the network for PEBB’s Statewide Plan when the new plan year starts?
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| A |
You will have guidance during the transition to the new plan year, which begins Jan. 1, 2010. You may complete and submit this form for help with transition of care (pdf). Case managers will consult with members who need care continuity for pregnancy, surgery and complex treatment of chronic conditions. Members may also talk with their providers about contracting to be in the network for PEBB’s Statewide.
Note that while physicians employed by the Legacy system are not listed as participating in Providence Health Plans’ network, services (including doctors and inpatient care) provided at Legacy facilities will be covered as in-network for pediatric specialty, high-risk obstetrics, burn and trauma services, and the bariatric surgery benefit covered in PEBB plans. The Legacy primary care clinics in Canby and Sandy and soon St. Helens (along with their urgent care clinic) will be participating in the network.
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| Q |
How will PEBB’s Statewide Plan cover healthcare when I travel?
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| A |
The plan will cover care for you and covered dependents when you travel, whether you travel out of state or internationally. The plan administrator will process claims for care you receive as required by PEBB contract. In addition, all members covered by the employer's basic life insurance have a healthcare coordination benefit when they travel, provided by Medex TravelAssist. If you or a dependent becomes ill while traveling 100 or more miles from home, Medex offers a range of assistance at no cost. Learn more.
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| Q |
Will I be able to rely on the same processes currently in place to get covered care when I travel?
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| A |
You should follow the same processes in 2010 as you use now. Have your healthcare plans’ ID cards with you – both medical and dental – and a copy of the Medex TravelAssist card or brochure. If you travel outside the U.S., take a copy of your plan’s claim form, as well. If you need to access care, ask the provider to contact your plan directly and immediately to make arrangements for claims.
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| Q |
How will the new plan cover emergency care at a hospital that’s not in the network?
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| A |
Your PEBB benefits cover emergency services in the emergency room of any hospital. Emergency services are covered at the in-network level when your medical condition meets the guidelines for emergency care. This coverage includes services to stabilize an emergency medical condition and emergency medical screening exams. Your plan will coordinate transition of care when your condition is stabilized.
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| Q |
What is the prescription drug formulary for PEBB’s Statewide Plan beginning 2010?
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| A |
Review the current formulary (pdf). Note that plans update formularies periodically.
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| Q |
Will I have to get another exception for the lower co-pay for my brand-name drug?
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| A |
Not in most cases. If you are taking a brand-name prescription drug that is not on the formulary, and your provider has shown that only the brand drug will work for you, you will typically continue to pay the lower co-pay for the medication.
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| Q |
Can my plan deny coverage for abortion, sterilization or physician-assisted suicide, or make me pay upfront to access this care?
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| A |
No. The Board designs the plans (what is covered and at what level), and PEBB contracts determine how claims are paid. It’s important to recognize that some doctors or hospitals in a plan’s provider network may choose not to offer certain covered services. It’s also important to choose healthcare providers based on personal values. Talk with your healthcare providers about decisions about your care.
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| Q |
Will the plans change how they coordinate benefits with other coverage?
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No. Insurance regulations determine how plans coordinate payment for benefits when members have coverage among different plans or dual coverage within the same plan. PEBB-sponsored plans follow these regulations.
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| Q |
Can I continue to opt out of PEBB medical plans if I have other group coverage?
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| A |
Yes. During Open Enrollment, Oct. 1-31, 2009, you must actively choose a medical plan for 2010. Opting out is a choice of medical plan. You may choose to opt out of coverage in a PEBB-sponsored medical plan if you have other group coverage that meets PEBB administrative rules. You must have proof of the other coverage on file with your agency within five days of enrolling. If you do not actively enroll for a medical plan (including opt out), you will be automatically enrolled in the employee-only tier of PEBB’s Statewide Plan beginning Jan. 1, 2010, and your dependents will lose coverage that date.
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| Q |
Will I be able to continue coverage in a self-insured plan if I lose eligibility? Do I have portability?
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| A |
Yes. If you lose PEBB eligibility (for example, if you lose your job), you will continue to have access to your plan through COBRA, the federal law on continuation of coverage. Your plan cannot impose exclusions or limitations that did not apply to you as a member, including those for pre-existing conditions. You will be responsible for paying the group-rate premium and an administration fee. In most cases, you may continue coverage through COBRA for 18 months; the term may be longer in some cases. At the end of your of COBRA coverage, you will be eligible for a portability plan through the Oregon Medical Insurance Pool if you meet their requirements. The plan must cover pre-existing conditions, and the premium must match typical group insurance rates.
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| Q |
If I enroll in the Kaiser Permanente HMO from another plan…
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Will I hear from them before my enrollment goes into effect?
A. Kaiser Permanente has communicated that you should receive separate mailings of your ID card and the applicable medical or dental directory prior to the effective date of coverage, which is Jan. 1, 2010. Kaiser Permanente has also communicated that, on Jan. 4, 2010, Membership Services staff will begin calling PEBB members to welcome them to Kaiser Permanente, answer questions about the plan and help them with transitioning from their previous provider.
How can I get help to transition from my current providers?
A. Kaiser Permanente has communicated that New Member Outreach staff will help you choose a new primary care providers, transfer medical records and arrange for prescription transfer. If you have questions or need help, you can call Membership Services. They are available by phone Monday-Friday, 8 a.m.-6 p.m.
How do I transfer my prescriptions?
A. Call the Kaiser Permanente pharmacy nearest you and give them your prescription numbers and the phone number of your current pharmacy. Ask them to call your current pharmacy after Jan. 1, 2010 to transfer your prescriptions. Or, you can complete and submit the Kaiser Permanente form for new members to transfer their prescriptions.
How will I get access to specialists for my complex medical condition?
A. The primary care provider you select will help you determine your care plan and will be your source of referral to specialty care. You may self-refer to Kaiser Permanente providers for outpatient treatment of chemical dependency and mental health; cancer counseling; optometry; obstetrics and gynecology; occupational health and social work. You may contact Membership Services for assistance.
Can I continue to see my current providers beginning Jan. 1?
A. In general, the plan will cover continuation of care outside the Kaiser Permanente system only for newly enrolled members who are in the third trimester of a high-risk pregnancy. These individuals will need to make arrangements with Kaiser. They can initiate the process through a call to Membership Services.
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| Providers and Provider Networks |
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| Q |
Will the network for PEBB’s Statewide Plan be a Providence-only network?
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No, the network will not be a “Providence-only” network or a network of only Providence providers. It will be a provider network that meets requirements of the PEBB contract, including requirements on national and international coverage.
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| Q |
Will I be limited to only Providence providers in PEBB’s Statewide Plan?
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No. The PEBB Statewide Plan is not a Providence plan, and the network for the Statewide Plan is not a network of only Providence doctors. The Statewide Plan is designed and insured by PEBB, instead of an insurance company. The plan offers statewide, nationwide and worldwide coverage through networks of providers. PEBB has selected Providence Health Plans to administer this PEBB-insured plan. This means they will process claims and contract with providers to be in the networks.
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| Q |
How do I find out if my provider is in the network for PEBB’s Statewide Plan?
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Use the provider search tool. Type in your provider’s name and zip code, and click “Go.”
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| Q |
I live outside the state’s borders but work in Oregon; will I need to change doctors?
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The Statewide Plan network includes a large number of providers across the country. You can search for the providers online through the MultiPlan Web site. Note that providers in the Boise area have recently joined the network.
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| Q |
I heard my providers are in the network; why don’t they show up in the search results?
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There could be a number of reasons:
- When you search for a specific provider, you must spell the name correctly – even one letter makes a difference. For example, typing in Kelley will not return results for Kelly. Using first and last names means more opportunity for error; try using the last name only. Check the tips on the returned-results page.
- The search sorts by distance from the zip code you enter, and your provider’s zip code may be outside the default radius. Try expanding the radius from the drop-down menu.
- Building and joining a provider network involves contracts; it can take a little time to get details in place.
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| Q |
Are most providers in the network for PEBB’s Statewide Plan?
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Currently, more than 95 percent of all providers used by PEBB members are already in the network. The plan administrator continues to broaden and refine the network. If your providers do not already contract to be in the network, you may want to encourage them to do so.
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How do I encourage my providers to be included in the network? |
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You can ask your provider, directly. You are an equal partner in your care, and there is power in partnerships. The implementation team is working through a process for PEBB members to “nominate” providers with whom they have an ongoing relationship; look for details in coming updates.
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| Q |
How can my providers apply to join the network for PEBB’s Statewide Plan? |
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They can call (888) 568-2482. This is a voice mailbox monitored by the network manager. Providers should leave their name, phone number, provider type, and county where they practice. They will receive a response within one business day. Providers can also fax a request to contract to (503) 574-8168.
Note that while physicians employed by the Legacy system are not listed as participating in Providence Health Plans’ network, services (including doctors and inpatient care) provided at Legacy facilities will be covered as in-network for pediatric specialty, high-risk obstetrics, burn and trauma services, and the bariatric surgery benefit covered in PEBB plans. The Legacy primary care clinics in Canby and Sandy and soon St. Helens (along with their urgent care clinic) will be participating in the network.
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| Q |
I will be undergoing treatment for a complex condition near the end of the year; how do I get help transitioning my care to the new plan? |
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It is very important for Providence Health Plans, the administrator for PEBB’s Statewide Plan, to understand any special health needs or medical conditions that you or your family members may have. For example, if you are currently receiving care from a Regence Preferred Provider for medical conditions (such as pregnancy in the third trimester, chemotherapy, radiation therapy, or preparing for an organ transplant), have special medication needs or have surgery scheduled in the weeks around the transition, they can help with your questions or concerns. Complete and submit the Transition of Care form (pdf). One of their Nurse Case Managers will contact you.
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I heard that providers in the Klamath area are contracting to be in network; why doesn't the provider-search show my specialist in Klamath Falls?
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Sky Lakes Medical Center and a majority of primary care providers in Klamath Falls are currently participating in the network for PEBB's Statewide Plan. Providence Health Plans is currently in discussions with the remaining providers in this community. The administrator expects to have a complete network in place by Jan. 1, 2010. If you are currently under the care of a physician who does not appear in the provider-search results, you may want to contact the physician's office to ask about their ability to continue your care as a participating provider in the Providence network.
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How can my mental-health counselor join the network?
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Providers of behavioral health services who want to participate in the network should call (800) 711-4577.
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Will OHSU hospital and providers be in the network for PEBB’s Statewide Plan?
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Yes. PEBB was able to accommodate requests that OHSU’s full provider panel be included in the network.
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| Q |
Will Legacy hospitals be in the network for PEBB’s Statewide Plan?
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Legacy facilities will be in-network for pediatric specialty, high-risk obstetric, burn, and trauma services, and the bariatric surgery benefit covered in PEBB plans.
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Are physical therapists included in the network?
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Yes. You can find in-network physical therapists through the provider search function. Type in the last name of the physical therapist and click “go.”
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Are providers of complementary and alternative care included in the network?
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Yes. PEBB plans cover complementary and alternative care, according to the plan’s design.
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| Q |
Does PEBB determine how much my providers are paid?
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No. Insurance companies and plan administrators negotiate reimbursement rates as part of discussions with providers on participating in a network. These rates determine what providers are paid when they submit claims for covered services. The Benefit Board plays no role in these negotiations. Kaiser Permanente, which is an HMO, owns its facilities and employs (or otherwise engages) its own providers. It may contract for services not offered inside the HMO. PEBB plays no role in these contracts.
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Do providers in the network accept the plan’s reimbursement plus my coinsurance as payment in full?
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Yes. That is one element that determines a provider’s participation in the network. Providers must meet other criteria, as well.
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Can out-of-network providers bill me for more than usual and customary rates?
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Yes, out-of-network providers may “balance bill.” You may want to ask out-of-network providers if they charge based on usual and customary rates; if they don’t, ask if they balance bill for their charges beyond usual and customary rates. If you choose to continue receiving care from an out-of-network provider who will charge more than the usual and customary rates and balance bill, you may want to compare how the charges will affect your healthcare costs in 2010. Note that your plan covers emergency care at the in-network rate when your medical condition meets the guidelines for emergency care.
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How can I compare one plan’s network with another?
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You will usually get more-accurate results by searching for specific providers rather than comparing networks. Provider networks are fluid; a provider not in the network today may be in-network tomorrow. Plans may sort their lists of providers using different criteria. For example, you may see a provider listed in one plan’s network under the heading of “internal medicine,” but that provider may work exclusively as a hospitalist who sees only patients admitted to a hospital. If a specific provider is not listed in a plan’s network, you may want to call the provider’s office to ask about network status.
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