Compare medical plans

Things to think about when choosing a medical plan

Choosing a medical plan is an important decision. Many people think first about cost and which doctors and hospitals are in the network. All PEBB Program medical plans, except for Premera Blue Cross Medicare Supplement Plan F, cover the same basic health care services but vary in other ways, such as provider networks, monthly plan costs, and prescription drug coverage.

As you research your plan options, consider these questions:

What are my costs for care?

Get a side-by-side comparison of common medical benefits and costs for services.

• Medical benefits comparison tool (online)
• Medical plan benefits comparison 2017 (printable)
• Medicare plan benefits comparison 2017 (printable)
• Medical plan benefits comparison 2016 (printable)
• Medicare plan benefits comparison 2016 (printable)

Are my providers in the plan's network?

Use the health plans' provider directories to find a provider near you and make sure the provider is in your plan's network. See Find a provider.

Do I live in the plan's service area?

In most cases, you must live in a medical plan’s service area to join the plan. See Medical plans available by county.

What are the monthly plan costs?

Higher plan costs don’t necessarily mean higher quality of care or better benefits; each plan has the same basic level of benefits. (except Medicare Supplement Plan F). Generally, the classic plans have higher monthly costs than the value plans. However, classic plans may have lower annual deductible, copays, or coinsurance costs. See Plan costs.

What kind of coverage does the plan offer?

Look at the plans' benefits booklets and Summaries of Benefits and Coverage to find out what is covered and your costs for care. See Benefits and coverage by plan.

How do the PEBB plans work with Medicare?

You must be enrolled in Medicare Part A and Part B to enroll in the Medicare Advantage or Medicare Supplement plans. Also, not everyone qualifies to enroll in a CDHP with a health savings account (HSA). See Medicare and PEBB benefits.

Medical plan types

The PEBB Program offers three types of medical plans:

Managed-care plans

Managed care plans may require you to select a primary care provider (PCP) within its network to fulfill or coordinate all of your health needs. The plan may not pay benefits if you see a non-contracted provider.

Preferred provider organization health plans

PPOs allow you to self-refer to any approved provider type in most cases, but usually provide a higher level of coverage if the provider contracts with the plan.

Consumer-directed health plans

CDHPs let you use a health savings account (HSA) to help pay for out-of-pocket medical expenses tax free, have a lower monthly premium than most plans, and a higher deductible and a higher out-of-pocket limit. Remember, if you cover eligible dependents, everyone must enroll in the same medical and dental plans (with some exceptions, based on eligibility for Medicare Part A and Part B). See Health savings account (HSA)

Medical plan options

In general, PEBB Program retirees may choose from the plans listed below. Your options are limited to the plans available in your county and whether you are enrolled in Medicare Part A and Part B. Remember, if you cover eligible dependents, everyone must enroll in the same medical plan (with some exceptions, based on eligibility for Medicare Part A and Part B).

Medicare options

• Group Health Medicare Plan (Medicare Advantage or Original Medicare coordination plan)
• Kaiser Permanente Senior Advantage
• Medicare Supplement Plan F, administered by Premera Blue Cross
• UMP Classic (Medicare), administered by Regence BlueShield

Non-Medicare options

Managed-care plans

• Group Health Classic
• Group Health Value
• Group Health SoundChoice (Note: At least one family member must not be enrolled in Medicare Part A and Part B.)
• Kaiser Permanente Classic

Consumer-directed health plans (CDHPs)

• Group Health CDHP
• Kaiser Permanente CDHP
• UMP CDHP, administered by Regence BlueShield

Preferred-provider plans

• UMP Classic, administered by Regence BlueShield
• UMP Plus, administered by Regence BlueShield (Note: Not available to retirees enrolled in Medicare Part A and Part B.)

Other plan differences to consider

Deductibles

All medical plans, except Group Health’s and Kaiser Permanente’s Medicare Advantage plans, require you to pay an annual deductible before the plan pays for covered services. UMP Classic also has a separate annual deductible for some prescription drugs. Preventive care and certain other services are exempt from the medical plans’ deductibles. This means you do not have to pay your deductible before the plan covers the service.

Coinsurance or copays

Some plans require you to pay a fixed amount, called a copay. Other plans require you to pay a percentage of an allowed fee when you receive care, called a coinsurance.

Out-of-pocket limit

The annual out-of-pocket limit is the most you pay in a calendar year for covered benefits. UMP Classic has a separate out-of-pocket limit for prescription drugs. Once you have paid this amount, the plans pay 100 percent of allowed charges for most covered benefits for the rest of the calendar year. Certain charges incurred during the year (such as your annual deductible, copays, and coinsurance) count toward your out-of-pocket limit. There are a few costs that do not apply toward your annual out-of-pocket limit:

• Monthly premiums and applicable surcharges.
• Charges above what the plan pays for a benefit.
• Charges above the plan’s allowed amount paid to a provider.
• Charges for services or treatments the plan doesn’t cover.
• Coinsurance for non-network providers.
• Prescription-drug deductible and prescription-drug coinsurance (UMP Classic only).

Referral procedures

Some plans allow you to self-refer to any network provider; others require you to have a referral from your primary care provider. All plans allow self-referral to a participating provider for women’s health care services.

Paperwork

In general, PEBB Program plans don’t require you to file claims. However, UMP Classic members may need to file a claim if they receive services from a non-network provider. CDHP members should also keep paperwork received from their provider or from qualified health care expenses to verify eligible payments or reimbursements from their health savings account.

Coordination with your other benefits

If you are also covered through your spouse’s or registered domestic partner’s comprehensive group health coverage, call the medical and/or dental plan(s) directly to ask how they will coordinate benefits. All PEBB Program plans (except Premera Blue Cross Medicare Supplement Plan F) coordinate benefit payments with other group plans, Apple Health (Medicaid), and Medicare. This is called coordination of benefits (COB). This coordination ensures benefit costs are more fairly distributed when a person is covered by more than one plan. However, the amount your PEBB Program plan pays for benefits will not change for a particular service or treatment, even if you or a dependent have an individual medical or dental policy covering that service or treatment.

Exception to coordination: PEBB Program plans that cover prescription drugs will not coordinate prescription drug coverage with Medicare Part D. All PEBB Program plans cover prescription drugs except Premera Blue Cross Medicare Supplement Plan F. If you enroll in Medicare Part D, you must enroll in Premera Blue Cross Medicare Supplement Plan F or lose your PEBB Program retiree coverage.

What should I consider when choosing a plan to go with Medicare Parts A and B?

• Are the services you need covered?
• How much are premiums, deductibles and other costs?
• How much do you pay for services like hospital stays and doctor visits?
• Do your doctors and other health care providers accept the coverage? Are they part of the plans network?
• Do you need to purchase a Medicare Part D prescription drug plan? Does the plan cover the medications you are currently taking?
• Are you satisfied with the quality of care and services given by the plan?
• Are the doctors and other health care providers conveniently located?
• If you travel, are you covered in another state or outside the US?