Health Plan Basics

• Provider Network
• Non-Participating Providers
• Preventive Care Coverage
• Deductibles
• Copayment &Coinsurance
• Out-of-Pocket Maximum

Our plans encourage you to work closely with one personal physician/provider to provide your care, but you are not required to select one. Plus, you can see specialists any time without a referral.

You receive the highest level of benefits (called In-Plan) when you use participating providers for covered health care services. You also benefit from having coordinated care – meaning providers in our network bill us directly and work with us to arrange your care.

Our plans provide access to an extensive network of participating doctors, hospitals and other health care providers, including:

• More than 8,000 health care physicians and providers, including specialists, in Oregon and southwest Washington.
• More than 200 hospitals and facilities, including Providence Health & Services hospitals and Providence Medical Group clinics, in Oregon and southwest Washington.
• A national network of participating providers.

Is your doctor an Individual and Family Plan participating provider? Search our Provider Directory.

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There may be times when you want to see a doctor who is not a participating provider. When you see a non-participating provider (called Out-of- Plan), you will pay a higher coinsurance and your deductible on most services. Plus, you will pay any amounts over Usual, Customary, and Reasonable Rates (UCR). These rates are based on the service provided and the geographic location of the provider.

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We believe that getting the right preventive care is essential for maintaining good health. All our plans cover preventive care prior to meeting your deductible.

Here's a list of preventive care services we cover:

• Well baby care
• Periodic health examinations
• Immunizations/shots
• Annual women’s health care exams
• Mammograms
• Men’s and women’s preventive care
• Prostate screening exams
• Colorectal screening exams

We cover periodic health examinations and well-baby care according to the following schedule.

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An annual deductible is the amount you pay for covered services before the plan will begin to pay for these services. A new deductible must be met each calendar year. Deductible amounts are listed in the Plan Comparison.

Optimum Plan and Value Plan deductibles:

• Individual deductible – Once a member meets the individual deductible, the plan will begin paying for covered services for that member.
• Family deductible – Applies when three or more people are enrolled on a family plan. All amounts paid towards the individual deductible by a family member are counted towards the family deductible. Once the family deductible is met, the plan will begin paying for covered services for all enrolled family members. (Note: No member will ever pay more than the individual deductible before the plan begins paying for covered services for that member.)
• Deductible Carryover – For Optimum and Value Plans, deductible amounts applied in the last three months of a calendar year will carry forward and apply toward the deductible for the following year.

HSA Plan deductibles:

• Individual deductible – Once the individual deductible is met, the plan will begin paying for covered services.
• Family deductible – Once the family deductible is met, the plan will begin paying for covered services for all enrolled family members.

Choosing a plan that works best for you – one with a higher or lower deductible – is a decision that is unique to your own coverage needs:

• A higher deductible plan means a lower monthly premium. In exchange for a lower premium, you pay a larger amount for certain covered services before the plan will begin to pay for those services.
• A lower deductible plan means a higher monthly premium. However, the plan will begin to pay sooner for certain covered services.

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After meeting your annual deductible, you and the health plan will begin to share the costs of covered health services through copayments and coinsurance.

• Copayment – Is a fixed dollar amount you pay for a covered service at the time care is provided.
• Coinsurance – Is a percentage of cost you pay for a covered service. Usually, your provider will bill you for your share of costs after care is provided.

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To protect you from catastrophic costs, our plans include an annual out-of-pocket maximum. An out-of-pocket maximum is the total amount you pay for covered services, after deductible, in a calendar year. After you meet your out-of-pocket maximum, the plan will pay 100 percent of covered services for the remainder of the calendar year. (Certain services do not apply to the outof-pocket maximum.) Our plans have different outof-pocket maximums for individual plans and family plans. See the Plan Comparison for details.

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