Benefits Basics

Overwhelmed by benefits? Start building your foundation here so you can take full advantage of the Specialized coverage options. The more you know about how insurance works, the easier it will be to choose and use your plans. 

MEDICAL PLAN BASICS

  • You start by paying a premium. This is the amount that comes our of your paycheck every month. Think of this as a bill for having the insurance coverage.
  • When you start incurring medical costs, you will pay the full cost of the expenses up until a certain amount known as the deductible*.
  • Once you reach your deductible, then your plan pays most* of the bills and you pay the rest.
  • But, say you need a lot more care during the year, you may hit what is called your out of pocket max*. This is the maximum amount that you will spend on healthcare for the remainder of the year. This is when your plan kicks in and pays for 100% of your care.
  • There are certain services that are 100% covered! This means, you pay nothing at all to use them. See your plan for specific information, but typically this includes things like preventive care, immunizations, routine hearing exams, and well-woman exams.
  • *Costs of the deductible, the amount your plan pays and the out-of-pocket max change by plan. See the plan comparisons to find the exact numbers.
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General Benefits Definitions and FAQ

  • What is a medical network?
    • A group of doctor's and hospitals that work within your insurance carrier umbrella. Doctors in your network will cost less money than doctors outside of your network, so you want to use these as much as possible.
  • What is the difference between a HMO vs a PPO?
    • A Health Maintenance Organization (HMO) gives you access to certain doctors and hospitals within a network. Medical care under a HMO plan is only covered if you see a provider within that HMO's network. Premiums are generally lower for HMO plans and there is usually no (or very low) deductible. This plan is a good option for teammates who plan on staying solely within their healthcare network. In short, they are more affordable, but come with more restrictions on which doctors you are allowed to see. 
    • A Preferred Provider Organization (PPO) still feature a network of providers, however they this plan is more flexible on covering you if you need to see a doctor outside of that network. PPO's are generally more expensive, but they offer more flexibility in doctors. This plan is a good option for teammates if you know that you might need to occasionally visit a doctor outside of the medical network. In short, they are more pricey, but come with fewer restrictions on which doctors you are allowed to see. 
  • What is a co-pay? A fixed amount that you pay when using covered health care services.
  • What is a FSA? A FSA is a Flexible Spending Account that exists to help you pay for medical, dental, or vision care. These funds are removed from your paycheck before taxes are taken out... so you save money!
    • What can you spend it on? You can spend your FSA money on any qualified medical expenses: doctor visits, prescriptions, over-the-counter medications, bandages, contact lens solutions, pregnancy tests, LASIK eye surgery, acupuncture, dental expenses, eyeglasses and many other healthcare expenses. You can see a full list here.
      • Your FSA will not cover things like vitamins, over-the-counter medications, elective surgery, and spa treatments.
    • Using an FSA does take some planning. For example, you know you will spend $1,000 next year on qualified FSA expenses, so you commit to save $1,000 in your FSA over the course of the year (that's only a little each paycheck!).  You also need to know, that once you've chosen the amount that you're committing to your FSA, you can't change your mind later.
    • Use it or lose it - The trick to using the FSA is to only contribute what you'll actually use because if you do not use it within the year, you'll lose your remaining FSA balance at the end of the year.
    • Should I contribute to a FSA? See the FSA page to see how costs compare for contributing to a FSA. 
  • How are prescription medications covered? Different medicines are covered at different levels or different "tiers." For specific tier level pricing, please refer to your specific insurance plan.
    • Brand-name: A drug that is discovered, developed and marketed by a pharmaceutical company. 
    • Generic: Copies of brand-name drugs that have exactly the same dosage, intended use, effects, risks, safety, etc. as the original drug. 
    • Formulary: Prescription drugs that the insurance carrier trusts and includes in insurance plans. These drugs have been tested and researched to be safe and effective. 
    • Non-formulary: Prescription drugs that are not covered by insurance policies. These drugs are more costly. 
  •  I am enrolled on dual medical plans, how do I coordinate my benefits? If you are enrolled in more than one medical insurance plan, the insurance companies will need to coordinate payment by determining which of your plans pays first. Insurance companies periodically send out a questionnaire to determine if a claim requires coordination of benefits. If your receive this questionnaire, simply send in the form as instructed or call a Care Coordinator to update your info so your claim can be processed and paid.