Group Health Options, Inc.

Transcription

1 FEDERAL EMPLOYEES RATES & BENEFITS Group Health Options, Inc Federal Plans Compare your plan options Choose the plan that fits you and your family

2 Why choose Group Health Options, Inc. The Network The GHO Federal network offers you broad in-network coverage. So you can find the doctor who s right for you wherever you are. It s also the only network that gives you access to the highest rated doctors* in the state at Group Health Medical Centers, and lets you choose from any licensed provider throughout the state. Plus, you get access to more than 600,000 in-network providers with the regional First Choice Health network and national First Health Network. In-Network Providers Access to an extensive network of physicians and other providers who contract directly with Group Health Access to in-network care from First Choice Health providers located in Washington, Oregon, Idaho, Alaska, and Montana Access to in-network care from First Health Network s providers in all states nationwide outside Washington, Oregon, Idaho, Alaska, and Montana Out-of-Network Providers Access to out-of-network care from any licensed provider, medical facility, and hospital in the country Out-of-Area Coverage Routine, urgent, and emergency care anywhere in the world Alternative care All plans include naturopathy, acupuncture, chiropractic, and massage therapy benefits. Dental care All plans include preventive dental benefits, and you can see any licensed dentist. Health and wellness programs Included in your plan at no extra charge are preventive care reminders, GlobalFit fitness club discounts, nutrition program discounts, and a smoking cessation program. Vision hardware Annual routine eye exams are covered at 100%. Also, obtain discounts on frames, lenses, contacts, and OSHA-approved safety goggles at Group Health Eye Care optical shops. * Highest-ranked medical group in Washington state, Washington Health Alliance, 2015 Community Checkup

3 Which plan is right for you? There are three GHO Federal plans available for 2016, so you can choose the coverage that fits your needs and budget. Group Health Options, Inc. High Deductible Health Plan Lower premium, with HSA or HRA If you and your family are healthy and anticipating few medical expenses during the year, you may want to consider the GHO Federal High Deductible Health Plan. The plan has lower premiums and a higher deductible. Preventive care services are covered at 100%, and the plan includes preventive dental coverage. The plan will be paired with a health savings account (HSA) or health reimbursement arrangement account (HRA) through HealthEquity. GHO will help your health care dollars go further by contributing to your account. And you can set aside tax-free dollars in your HSA account up to the IRS limits. Learn more about HSAs and HRAs at healthequity.com. Group Health Options, Inc. Standard Option Low deductible This low-deductible GHO Federal medical plan covers all your preventive care visits at 100%, and all other professional office visits with just a $20 copay (not subject to deductible). The plan also includes preventive dental coverage. Group Health Options, Inc. High Option No deductible This zero-deductible GHO Federal medical plan covers all your preventive care visits at 100%. It also includes preventive dental coverage and up to $1,000 of dental coverage for basic and major dental procedures. TYPE OF ENROLLMENT Biweekly Your Share Non-Postal Premium Monthly Your Share Biweekly Category 1 Your Share Postal Premium Biweekly Category 2 Your Share HIGH DEDUCTIBLE PLAN Self Only Code L14 $56.20 $ $46.65 $56.20 HIGH DEDUCTIBLE PLAN Self Plus One Code L16 $ $ $97.30 $ HIGH DEDUCTIBLE PLAN Self and Family Code L15 $ $ $ $ STANDARD OPTION Self Only Code L11 $71.96 $ $60.10 $71.96 STANDARD OPTION Self Plus One Code L13 $ $ $ $ STANDARD OPTION Self and Family Code L12 $ $ $ $ HIGH OPTION Self Only Code VT1 $ $ $ $ HIGH OPTION Self Plus One Code VT3 $ $ $ $ HIGH OPTION Self and Family Code VT2 $ $ $ $ Please note that the above information is a summary of the GHO Federal benefits. It is not a contract. For complete information, and before making a final decision, please read the 2016 federal brochure posted at ghofederal.org. All benefits are subject to the definitions, limitations, and exclusions set forth in the brochure. These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to your special FEHB Guide or contact the agency which maintains your health benefits enrollment. If you need help to find a plan that s right for you, please call the GHO Federal Program Sales Department at For current members, contact Customer Service toll-free at See Details and definitions on the back for explanations of some of the terms used in this brochure.

4 GHO FEDERAL HIGH DEDUCTIBLE HEALTH PLAN COVERAGE Plan Non-Plan Annual deductible Deductible applies to all services except as noted Annual out-of-pocket limit Annual medical fund contribution BENEFITS (Deductible applies unless stated not subject to deductible) Preventive care Professional services: (Self-refer / unlimited visits) Primary & Specialty Office, Home, Naturopath & Urgent Care Visits Acupuncture: Self-refer 20 visits per member PCY For substance abuse, unlimited visits Chiropractic: Self-refer 20 visits per member PCY Massage: With a referral, 20 visits per member PCY Mental health* Lab/X-ray Hospital / Facility Emergency care Maternity Ambulance: Ground & Air PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Nonformulary Tier 4: Formulary specialty Tier 5: Nonformulary specialty DENTAL Preventive Dental Basic & Major Dental Services Deductible: No annual maximum for children through age 17 VISION Annual routine eye exam Diagnostic eye exams Eyeglasses or contact lenses Accident or surgery related Hardware WORLDWIDE TRAVEL BENEFIT (OUTSIDE WA STATE) $1,500 / $3,000 / $3,000 $1,500 / $3,000 / $3,000 $4,000 / $8,000 / $8,000 $4,000 / $8,000 / $8,000 $750 / $1,500 / $1,500 $750 / $1,500 / $1,500 Covered in full, not subject to deductible : Outpatient & Inpatient* : Outpatient & Inpatient* : Prenatal care covered at 100%; not subject to deductible $10 copay / $20 copay $35 copay / $70 copay $50 copay / $100 copay 25% coinsurance up to $200 35% coinsurance up to $300 All charges in excess of scheduled allowance Covered in full; not subject to deductible Deductible and Deductible and 20% discount You pay applicable benefit cost shares PCY = Per calendar year *Inpatient requires preauthorization Please note that the above information is only a summary of Group Health Options, Inc. benefits. For complete information on benefit limitations, exclusions, and definitions, please refer to the Group Health Options, Inc. Federal Brochure posted at ghofederal.org.

5 GHO FEDERAL STANDARD OPTION COVERAGE Plan Non-Plan Annual deductible Deductible applies to all services except as noted Annual out-of-pocket limit Annual medical fund contribution BENEFITS (Deductible applies unless stated not subject to deductible) Preventive care Professional services: (Self-refer / unlimited visits) Primary & Specialty Office, Home, Naturopath & Urgent Care Visits Acupuncture: Self-refer 20 visits per member PCY For substance abuse, unlimited visits Chiropractic: Self-refer 20 visits per member PCY Massage: With a referral, 20 visits per member PCY Mental health* Lab/X-ray Hospital / Facility Emergency care Maternity Ambulance: Ground & Air PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Nonformulary Tier 4: Formulary specialty Tier 5: Nonformulary specialty DENTAL Preventive Dental Basic & Major Dental Services Deductible: No annual maximum for children through age 17 VISION Annual routine eye exam Diagnostic eye exams Eyeglasses or contact lenses Accident or surgery related Hardware WORLDWIDE TRAVEL BENEFIT (OUTSIDE WA STATE) $350 / $700 / $700 $5,000 / $5,000 / $5,000 Unlimited Covered in full, not subject to deductible $20 copay per office visit; not subject to deductible $20 copay per visit; not subject to deductible $20 copay per visit; not subject to deductible $20 copay per visit; not subject to deductible Inpatient*: Outpatient: $20 copay per visit; not subject to deductible : Outpatient & Inpatient Covered in full; not subject to deductible $10 copay / $20 copay $35 copay / $70 copay $50 copay / $100 copay 25% coinsurance up to $200 35% coinsurance up to $300 All charges in excess of scheduled allowance Covered in full; not subject to deductible Deductible and Deductible and 20% discount You pay applicable benefit cost shares PCY = Per calendar year *Inpatient requires preauthorization Please note that the above information is only a summary of Group Health Options, Inc. benefits. For complete information on benefit limitations, exclusions, and definitions, please refer to the Group Health Options, Inc. Federal Brochure posted at ghofederal.org.

6 GHO FEDERAL HIGH OPTION COVERAGE Plan Non-Plan Annual deductible Deductible applies to all services except as noted None None Annual out-of-pocket limit Annual medical fund contribution BENEFITS (Deductible applies unless stated not subject to deductible) Preventive care Professional services: (Self-refer / unlimited visits) Primary & Specialty Office, Home, Naturopath & Urgent Care Visits Acupuncture: Self-refer 20 visits per member PCY For substance abuse, unlimited visits Chiropractic: Self-refer 20 visits per member PCY Massage: With a referral, 20 visits per member PCY Mental health* Lab/X-ray Hospital / Facility Emergency care Maternity Ambulance: Ground & Air PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Nonformulary Tier 4: Formulary specialty Tier 5: Nonformulary specialty DENTAL Preventive Dental Basic & Major Dental Services Deductible: No annual maximum for children through age 17 VISION Annual routine eye exam Diagnostic eye exams Eyeglasses or contact lenses Accident or surgery related Hardware WORLDWIDE TRAVEL BENEFIT (OUTSIDE WA STATE) $5,000 / $5,000 / $5,000 Unlimited Covered in full $30 copay per office visit $30 copay per visit $30 copay per visit $30 copay per visit Inpatient*: Outpatient: $30 copay per visit : Outpatient & Inpatient $150 copay per visit; copay waived if admitted Covered in full $5 copay / $10 copay $25 copay / $50 copay $50 copay / $100 copay 25% coinsurance up to $200 35% coinsurance up to $300 All charges in excess of scheduled allowance $25 / $50 / $50 All charges in excess of scheduled allowance $1,000 annual maximum for adults 18 and older Covered in full $30 copay per visit 20% discount You pay applicable benefit cost shares PCY = Per calendar year *Inpatient requires preauthorization Please note that the above information is only a summary of Group Health Options, Inc. benefits. For complete information on benefit limitations, exclusions, and definitions, please refer to the Group Health Options, Inc. Federal Brochure posted at ghofederal.org.

7 How to get care when you re not near a Group Health clinic How to get care With Group Health Options, Inc. Federal plans, you have the freedom to self-refer to health care providers with just a few exceptions (referrals are required for speech, occupational, physical, and massage therapy providers). So, by using the GHO Federal network, which includes First Choice Health network, and First Health Network, you can be assured that you re covered. (Outside the state of Washington, a plan provider is a First Choice Health network or First Health Network provider.) If you receive care from non-plan providers and facilities, non-affiliated hospitals, or medical centers, you may be required to pay in full at the time of service. But don t worry, just mail us your completed claims form and medical receipts so we can reimburse you for any covered charges. You ll find claims forms on ghofederal.org. Search How to Submit Claims for Reimbursement. Or you can request one by calling Customer Service toll-free at How do I find a provider when I m traveling? You can always call Customer Service toll-free at for assistance. Your health care dollars will go further when you use our preferred regional and national networks: The First Choice Health network and the First Health Network. Find out more about these networks in our online Provider and Facility Directory; you ll find the link at ghofederal.org. How do I get a prescription? No matter where you get care, you can use thousands of convenient pharmacy locations for your prescription needs. For example, you can use pharmacies at Group Health Medical Centers, Virginia Mason, Swedish Physicians, and The Everett Clinic locations. We also offer an extensive nationwide pharmacy network OptumRx. To find a pharmacy near you, check out our Provider and Facility Directory; the link is at ghofederal.org. For refills that have been filled at least once at a Group Health Medical Centers pharmacy (or that have been transferred into our pharmacy system), you can phone in your prescription, use the Group Health mobile app (ghc.org/mobile), or make a request online (ghc.org/pharmacy) for pick-up at a Group Health Medical Centers pharmacy or for home delivery by mail. Search for Pharmacy Services on our website. How do I get a prescription in an emergency when I m traveling? Outpatient medications prescribed or dispensed as a part of an emergency or urgent situation will be covered. You may be required to pay for the total cost of the prescription up front, but can submit a request form for reimbursement upon your return home. You ll find claims forms on ghofederal.org. Search How to Submit Claims for Reimbursement. You can also request one by calling us toll-free at

8 Details and definitions Coinsurance A percentage amount you pay for a covered service or prescription. For example, you might pay 20 percent of the cost of your office visit each time you see your doctor. Copayment, copay A fixed dollar amount you pay for a covered service or prescription. For example, you might pay a $20 copay each time you see your doctor. Deductible What you ll pay each year before your coverage kicks in. For certain services, such as preventive care, the deductible does not apply. Health savings account (HSA) An HSA is a personal savings account that s used to pay for eligible medical expenses. The money you deposit into your account is not taxed, and you own and control that money, even if you change employers. Health reimbursement arrangement (HRA) An HRA is an account set up by an employer and used to pay for eligible medical expenses. The money deposited into the account is not taxed. Only the employer can contribute to an HRA and the employer controls the account. Out-of-pocket limit The most you ll be required to pay for covered services in a calendar year. After you ve paid this amount, the health plan pays for all covered services for the remainder of the year. Deductible, coinsurance, and copays count toward limit. Outpatient surgery Surgery in an office, outpatient surgery center, or hospital setting that does not require an overnight stay. Prescription drugs Outpatient: Formulary drugs and medicines that require prescriptions, including self-administered injectables, mental health drugs, and diabetic supplies. Preventive care services For children and adults: Includes wellness visits and immunizations, as established in Group Health Options, Inc. well-care schedule, and formulary contraceptive drugs, including counseling, contraceptive devices, and female sterilization. Devices and supplies related to contraception are covered as preventive as required by federal law and covered in full. Also includes drugs and medicines such as aspirin, fluoride, and folic acid. Hospital stays inpatient Hospital room and board; inpatient surgery; anesthesia; intensive and coronary care; laboratory tests; radiology services; and drugs while in the hospital. Includes mental health inpatient treatment. Coverage provided by Group Health Options, Inc. LG