Choosing a Medical Plan
Medical Plan Options
Before you choose your medical plan, you need to understand:
- The two types of plans that are available—managed care and preferred provider plans
- Whether a particular plan is available in your county—
- How much a plan will cost,
- Whether your current physician participates in the plan, or how to select a physician that participates in the plan in which you are interested,
- What terms like copay, co-insurance, premium and deductible mean.
Explanation of Terms
The amount you pay on a claim when your plan pays less than the claim's full amount.
- Copay (sometimes called a copayment)
The fixed cost you pay for service at the time you receive care.
- Annual deductible
This is the amount you must pay each calendar year before the plan pays benefits for covered expenses. PEBB plan deductibles vary greatly, with the Consumer Directed Health Plans (CDHPs) having the highest deductibles. Depending on the plan, payment for some services may not apply to the annual deductible.
The monthly amount plan enrollees pay for the cost of their health insurance. Premiums vary in cost depending on the health plan and the number of family members covered.
Compare medical premiums.
- Annual out-of-pocket maximum
The most you would have to pay toward the majority of covered expenses in a calendar year. After you reach your out-of-pocket maximum, the plan will pay 100 percent of most covered expenses for the rest of the calendar year.
- Allowed charges
The maximum amount your insurance plan will pay for covered services, treatments, or supplies.
Managed Care Plans
A managed care plan has a network of approved providers. It usually requires you to select a primary care provider (PCP) from within its network of approved providers, who manages and coordinates your care. You typically cannot see another provider unless referred by the PCP.
There are two types of managed care plans—Value and Classic. Value plans generally have lower monthly premiums but higher deductibles or out-of-pocket expenses.
The managed care plans:
- Group Health Classic
- Group Health Value
- Kaiser Permanente Classic
Value plan have the following attributes when compared to classic plans.
- They may require annual deductibles (classic plans do not);
- They may require higher copays for brand name prescription drugs purchased by mail order.
- They may require higher copays for office visits.
- They have higher annual out-of-pocket maximums.
Preferred Provider Organization (PPO)
The Uniform Medical Plan Preferred Provider Organization (UMP PPO) covers most services, subject to an annual deductible. A Preferred Provider Organization (PPO)
generally allows you to self-refer to any approved provider. However, the plan provides a higher reimbursement when the provider is part of the preferred provider network.
The UW's PPO plan is Uniform Medical Plan (UMP). UMP provides worldwide coverage for routine and emergency care.
Comparing Medical Plans
The general differences between PPO and managed care plans are:
- Out-of-pocket expenses
- Choice of doctors, hospitals, and pharmacies
- Referral practices and guidelines
- County where plan is available
For details on specific benefits, contact the plans directly.
You can also view an explanation of the medical plans and medical insurance options on the Benefits & WorkLife Medical Insurance web page.
Finding a Doctor
Your doctor should be listed in the provider directory. Search by individual provider or by hospital/clinic, and record the physician or clinic code.