Change of Health Insurance Providers
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1. How will the health care plan
change?
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New providers. Under the proposed
new health care plan, Group Health Cooperative will be the insurance provider,
under the Group Health “Options” plan, providing medical and vision insurance.
Dental insurance will be provided by
Washington Dental Service (WDS) (see end of these FAQs for more details on WDS).
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Deductible.
The medical deductible will increase from $300 to $500
per person; the family rate will be three times tis rate or $1,500 maximum. Please
click here
for a more detailed summary of benefits.
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Out-of-pocket max. Under the
medical plan, the out-of-pocket maximum (the maximum amount you pay out of
pocket for medical services) will decrease from $2,500 to $2,000 per person;
the family plan rate will be three times that amount.
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Benefit coverage.
The co-insurance level (the amount the
insurance company pays) for providers “in network” with Group Health will
increase from 80% to 90%. The
co-insurance level for providers “out of network” will increase from 50% to
80%.
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Mental health benefits.
Mental health benefits for both in-patient and out-patient services will be
unlimited.
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Preventive care.
Preventive care co-insurance (the amount
the insurance company pays) will increase from 80% to 100%.
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Prescription drugs.
Prescription drug co-pays will change from a three-tier payment system ($10
co-pay for generic drugs/$20 for brand name/$40 for non-formulary), to a
two-tier payment system ($10 generic/$20 brand In-Network; and $15 generic/$25
brand Out-of-Network).
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Vision coverage.
Vision
coverage will be provided for all medical plan enrollees, including all
enrolled dependants
.
2. Do I have to change my health
care provider?
No. With the Group Health Options Plan, you may see any licensed health
care provider. Coverage will be
determined by whether the provider is “in network,” a “participating provider,”
or “out of network,” as follows:
·
In network – 90% coverage. If your health care provider is
contracted with Group Health (an “in network” provider), simply select them as
your Primary Care Provider (PCP) by calling Group Health Customer Service once
you are enrolled at 1-888-901-4636. All provider charges will be paid at
90% after the deductible has been satisfied.
This is 10% better co-insurance than Regence currently provides.
·
Participating provider – 80% coverage with no balance
billing.
If your provider is not contracted with Group Health
but is contracted with First Choice Health Network (a “participating” provider),
Group Health will pay 80% of provider charges after the deductible has been
satisfied. And there will be no
“balance billing,” meaning that your doctor can’t charge you for the “balance”
of her fees, above the cost she has contracted for with First Choice—so you
truly pay only 20% for services.
·
Out of Network – 80% coverage with balance billing. If your current provider is not
contracted with Group Health (an “out of network” provider), you may continue to
see them. Group Health will pay 80% of provider charges after the deductible has
been satisfied, but your doctor can balance bill you, meaning that your doctor
can charge you for fees above the cost paid for by Group Health.
3. How do I find
out if my provider is contracted with either Group Health or First Choice Health
Network?
To find Group
Health “in network” providers, go to
www.ghc.org/provider/index.jhtml. Click on the “Provider Directory Link.”
Select “Options” from the drop down box. Enter in the name of the provider
you are looking for under the “Search by provider name.” For providers within
San Juan County,
you can see a list that compares providers to your current provider list.
For “participating providers” with First Choice Health network, go to
www.fchn.com.
Click on the “Click Here to Find a Doctor or Hospital” button in the upper left
hand corner of the screen. You may then search for a provider by name,
specialty, or location.
4. Where can I see a more
detailed benefits comparison with my current health insurance plan?
For a
more detailed summary of the benefits you have under Regence Blue Cross,
compared to the proposed new plan under Group Health,
click here.
5. Does Group Health Cover
Non-Formulary Medications?
Yes. Prescription drug coverage is handled in one of two ways. If
your prescription is on the Group Health formulary and is dispensed from a Group
Health contracted pharmacy (“in network”), you will pay either a $10 co-pay for
generic drugs, or a $20 co-pay for brand name drugs.
If your prescription is dispensed
from a non-Group Health pharmacy (an “out of network” pharmacy), you will pay
either a $15 co-pay for generic or a $25 co-pay for brand name drugs.
Dispensing of a generic drug is required unless a brand drug is medically
necessary.
To receive the lowest co-pays,
members should use a Group Health contracted pharmacy (“in network”)
and receive formulary
medications.
6. Are there Group Health
Contracted Community Pharmacies located in
San Juan
County?
Yes. Friday Harbor Drug in Friday Harbor, Ray’s Pharmacy in Eastsound, and
Lopez Island Pharmacy on Lopez Island are contracted with Group Health as “in
network” providers.
7. Do I need a referral to see a
specialist?
A referral is
not necessary for outpatient services at the “out-of-network” benefit level.
Pre-authorization by your primary care physician is only needed for outpatient
high-end radiology (such as an MRI) and scheduled inpatient hospitalization.
Payment for these services will be made
at 80% of provider charges after the deductible has been satisfied. If the
specialist is contracted with First Choice Health Network, there will be no
balance billing; if it is not, there can be balance billing.
To receive benefits at the 90% payment level,
in many cases, you must have a referral from your Primary Care Provider (PCP) to
see contracted specialists.
8. What happens
to my outstanding claims with Regence Blue Cross?
If you have an active claim disputing past health care coverage or billing with
Regence, your claim will continue with Regence until it is resolved. If your claim regards a
future coverage or billing with Regence, as of January 1, 2010, your new
Group Health plan will determine future
coverage or billing issues. You
should work with the County’s brokers, Mark Rose or Christine Morgan at Baldwin
Resource Group, if you need further advice or help with the claims process.
9. What happens
with continuing treatments I am receiving from my health care provider?
Changing to a new health insurance plan should not interrupt health care
services you receive from your current health care provider. You will need to present your health
care provider with your new insurance information, including your new enrollment
card. There may be differences in
what you pay, and how health care providers are paid, by Group Health compared
to Regence, depending on whether the health care provider is “in network,” a
“participating provider,” or “out of network,” as discussed above.
10. Are my enrolled dependents covered up to age 25?
Yes. Under a recently-enacted law,
enrolled dependents are covered up to age 25.
This is true for any health insurance plan in the State of
Washington, including the proposed new Group Health
Options plan.
11. What about
my dental plan—how will it change?
If you are a member of AFSCME Local 1849 or are
unrepresented, your current dental plan is offered only through Regence. If the County moves to Group Health,
it will contract with Washington Dental Service (WDS) to provide dental
insurance to you and your dependents.
For more information on WDS, see
www.deltadentalwa.com.
Click here
to see a side-by-side comparison (at the bottom of the chart).
The Sheriff’s Guild currently subscribes to WDS, so if you are a member of the
Sheriff’s Guild, your dental service network will not change, though your plan
options will.
12. Do I have to change my dental care provider?
No. You can continue seeing your
current dentist. If your dentist is
a WDS Delta Dental PPO dentist, you will have no dental deductible, and no
balance billing. If your dentist is a WDS Delta Dental Premier dentist you will
have no balance billing. Services at
out-of-network dentists are covered at the same coinsurance, but there could be
balance billing. To find out if your dentist is a WDS dentist, visit
www.deltadentalwa.com and click on
“Find a Dentist.”
13. Can I enroll
my dependents on the new dental plan?
Yes.
For the first time, if you are a member of AFSCME Local 1849 or an
unrepresented employee, you may enroll your dependents on your County dental
insurance plan. The County will pay
for your own “self” enrollment, and you must pay 100% of the premium for your
dependents. In other words, the
County will pay 100% of the “self” rate for you, and you will pay the difference
between the “self” rate and the dependent coverage option that you choose.
If you are a member of the Sheriff’s Guild, you already have your dependents
enrolled, and this will not change.
14. With new dependents enrolled on the County dental plan,
will our rates shoot up next year?
No.
Like car insurance, insurance rates rise with higher use, or higher
“utilization.” We have anticipated
that with dependents newly added to the County’s group dental plan, there will
be a spike in utilization during 2010.
We have, therefore, with WDS for two years, during which the
rates stay the same for both 2010 and
2011. This ensures that even with
higher utilization in 2010, the rates will not shoot up in 2011. There are no guarantees for 2012.
15. Who
do I contact with further questions about the change in medical and dental
plans?
You can contact
County
Administration with questions:
Adina Cunningham, adinac@sanjuanco.com
Pamela Morais,
pamelam@sanjuanco.com
You can also contac the County's health insurance brokers, Mark Rose or
Christine Baldwin Resource Group, at 877-455-5640. Their website is:
http://www.BaldwinRGI.com
16. How was the final decision be made?
Local 1849. On December 5, 2009, the Local 1849 membership voted
unanimously to make this change.
Sheriff’s Guild. The Sheriff’s Guild decided to make this change
through the collective bargaining process.
Management and Other employees. on Tuesday, December 8, 2009, the
Administrator recommended that the Council approve the change and the Council
voted to approve the change.