Things to think about when choosing a medical plan
When selecting a SEBB medical plan, your options are based on eligibility and where you live or work. You must consider which medical plans are available in your county of residence. If you cover eligible dependents, everyone must enroll in the same medical, dental, and vision plans.
Am I eligible to enroll in the plan?
SEBB medical plans may have criteria for eligibility. For example, not everyone qualifies to enroll in a high-deductible health plan (HDHP) with a health savings account (HSA).
Do I live in the plan's service are?
In most cases, you must live or work in a medical plan’s service area to join the plan. All school employees are offered a selection of plans based on their county of residence or the county where their school district, charter school, or educational service district is based. Some school employees may have more plan options if they work in a district that crosses county lines.
Be sure to contact the medical plans you’re interested in to ask about provider availability based on where you live. If you move out of your medical plan’s service area, you may need to change your plan. You must report the change to your payroll or benefits office no later than 60 days after your move.
How do I compare the plans?
Get a side-by-side comparison of common medical benefits and costs for services.
Plan differences to consider
If you want to see a specific doctor or health care provider, you should contact the medical plan (not your provider) to verify whether they are in the plan’s network before you join.
All health carriers in Washington State are required to maintain provider networks that provide enrollees reasonable access to covered services. Check the plans’ provider directories to see how many providers are accepting new patients and what the average wait time is for an appointment. Beginning in 2020, for mental health and substance abuse treatment, carriers must also provide additional information on their websites to consumers on the ability to ensure timely access to care. View the behavioral health benefits comparison. For more information, see Engrossed Substitute House Bill 1099 (Brennen’s Law).
If you have received prior authorization for any services under your current plan, it is important that you research which medical plans will honor existing preauthorization and for how long. This information is available on the medical plan’s website, or in their certificates of coverage. Contact the medical plan for more information.
Coordination with your other benefits
If you are also covered through your spouse’s or state-registered domestic partner’s comprehensive group medical coverage, call the medical, dental, and/or vision plans directly to ask how they will coordinate benefits. This is especially important for those coordinating benefits between the PEBB and SEBB Programs, and those also enrolled in Apple Health (Medicaid).
All SEBB medical plans coordinate benefit payments with other group medical plans, Medicaid, and Medicare. This coordination ensures the reimbursement for services when a person is covered by more than one plan. Note: If you have other comprehensive health coverage, you may not enroll in an HDHP with an HSA. Call HealthEquity at 1-844-351-6853 to ask about certain exceptions.
A premium is the amount the employee or employer pays to the plan to cover the cost of insurance. Premium amounts vary by medical plan. A higher premiums doesn't necessarily mean higher quality of care or better benefits; each plan has the same basic level of benefits. View plan costs for school employees or SEBB Continuation Coverage subscribers.
All medical plans require you to pay plan costs, such as fees for office visits, before the plan pays for covered services. This is known as the deductible. Medical plans may also have a separate annual deductible for specific prescription drugs. Note: Covered preventive care services are exempt from the medical plans’ deductibles. This means you do not have to pay your deductible before the plan pays for the covered preventive service.
Note: If you enroll in an HDHP, keep in mind:
- If you cover one or more dependents, you must pay the entire family deductible before the plan begins paying benefits (except for covered preventive care).
- The HDHPs have a combined medical and prescription drug deductible that must be met before the plan begins to pay for benefits. This means you will pay the full cost of your medical claims and prescription drugs until you meet your deductible.
Coinsurance or copays
Some medical plans require you to pay a fixed amount when you receive care, called a copay. Other medical plans require you to pay a percentage of an allowed fee, called coinsurance.
The annual out-of-pocket limit is the most you pay in a calendar year for covered benefits. Some plans have 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 out-of-pocket limit. See the plans’ certificates of coverage for specifics.
Some medical 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.
In general, the medical plans don’t require you to file claims. However, Uniform Medical Plan (UMP) members may need to file a claim if they receive services from an out-of-network provider. HDHP members also should keep paperwork received from their provider or for qualified health care expenses to verify eligible payments or reimbursements from their health savings account.
What type of plan should I select?
There are three types of medical plans: high-deductible health plans (HDHP), managed care plans (also known as a health maintenance organization or HMO), and preferred provider organization (PPO) plans. In addition, some plans are also value-based.
Value-based plans aim to provide high-quality care at a lower cost. Providers have committed to follow evidence-based treatment practices, coordinate care with other providers in your network, and meet specific criteria about the quality of care they provide. This means your providers are dedicated to ensuring you get the right care at the right time, which usually results in lower out-of-pocket costs for you. Value-based plans are noted below by an asterisk (*).
High-deductible health plans (HDHPs)
HDHPs let you use a health savings account (HSA) to help pay for out-of-pocket qualified medical expenses tax-free, have a lower monthly premium than most other medical plans, a higher deductible, and a higher out-of-pocket limit.
- UMP High Deductible (administered by Regence BlueShield and Washington State Rx Services (WSRxS))
Managed-care plans may require you to select a primary care provider within the medical plan’s network to fulfill or coordinate all of your health needs. Some outpatient specialty services are available in network participating medical offices without a referral. This type of plan may not pay benefits if you see a noncontracted provider for nonemergency services. Value-based plans are noted below by an asterisk (*).
- Kaiser Permanente NW 1*
- Kaiser Permanente NW 2*
- Kaiser Permanente NW 3*
- Kaiser Permanente WA Core 1*
- Kaiser Permanente WA Core 2*
- Kaiser Permanente WA Core 3*
- Kaiser Permanente WA SoundChoice*
Preferred provider organization (PPO) plans
PPOs allow you to self-refer to any approved provider in most cases, but usually provide a higher level of coverage if the provider contracts with the plan. Value-based plans are noted below by an asterisk (*).
- Kaiser Permanente WA Options Access PPO 1
- Kaiser Permanente WA Options Access PPO 2
- Kaiser Permanente WA Options Access PPO 3
- Premera High PPO
- Premera Peak Care EPO*
- Premera Standard PPO
- UMP Achieve 1 (administered by Regence BlueShield and Washington State Rx Services (WSRxS))
- UMP Achieve 2 (administered by Regence BlueShield and Washington State Rx Services (WSRxS))
- UMP Plus–Puget Sound High Value Network (administered by Regence BlueShield and Washington State Rx Services (WSRxS))*
- UMP Plus–UW Medicine Accountable Care Network (administered by Regence BlueShield and Washington State Rx Services (WSRxS))*