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 medical plans cover the same basic health care services, but vary in other ways such as provider networks, premiums, your out-of-pocket costs, and prescription drug coverage.

When selecting a PEBB medical plan, your options are limited based on eligibility and where you live. You must consider which plans are available in your county. Remember, if you cover eligible dependents, everyone must enroll in the same medical and dental plans.

As you research your plan options, consider these questions:

Am I eligible to enroll in the plan?

Not everyone qualifies to enroll in a CDHP with a health savings account (HSA) or a UMP Plus plan. See Health plans with health savings account (for CDHP eligibility information).

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. If you move out of your plan's service area, you may need to change your plan. You must report your new address 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.

• Medical benefits comparison tool (online)
• Medical plan benefits comparison 2021 (printable)

Plan differences to consider

Premiums

A premium is the monthly amount the employee or employer pays to the plan to cover the cost of insurance. The premium does not cover copays, coinsurance, or deductibles. Premium amounts vary by medical plan. A higher premium doesn’t necessarily mean higher quality of care or better benefits; each plan has the same basic level of benefits. Generally, plans with higher premiums may have lower annual deductibles, copays, or coinsurance costs. Plans with lower premiums may have higher deductibles, coinsurance, copays, and more limited networks. It is important to consider all of these when choosing a plan. See plan costs to see premiums for all medical plans.

Note: If you are employed by a school district, educational service district, charter school, city, county, tribal government, port, water district, hospital, or other employer group, contact your payroll or benefits office to find your monthly premium.

Deductibles

Most medical plans require you to pay a certain amount of 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. Covered preventive care services are exempt from the medical plan deductible. This means you do not have to pay your deductible before the plan pays for the covered preventive service.

Plan benefits

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

Coinsurance or copays

When you receive care, some plans require you to pay a fixed amount, called a copay. Other plans require you to pay a percentage of an allowed fee, called coinsurance. These amounts vary by plan and are based on the type of care received.

Out-of-pocket limit

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 reached the out-of-pocket limit, the plan pays 100 percent of allowed charges for most covered benefits for the rest of the calendar year. Certain charges (such as your annual deductible, copays, and coinsurance) may count toward your out-of-pocket limit. Others, such as your monthly premiums, do not count toward your out-of-pocket limit.

Referral procedures

Some plans allow you to self-refer to network providers for specialty care. Others require you to have a referral from your primary care provider. After you join a medical plan, you may change your provider, although the rules vary by plan.

Your provider

If you have a long-term relationship with your doctor or health care provider, you should verify whether they are in the plan's network. See Find a provider.

Network adequacy

All health carriers in Washington State are required to maintain provider networks that provide members 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. For more information, see Engrossed Substitute House Bill 1099 (Brennen’s Law).

Coordination with your other benefits

All PEBB medical plans coordinate benefit payments with other group plans, Apple Health (Medicaid), and Medicare. This is called coordination of benefits. It ensures the highest level of reimbursement for services when a person is covered by more than one plan. Payment will not exceed the benefit amount. If you are also covered by another health plan, call the medical 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). PEBB medical and dental coverage is limited to a single enrollment per individual.

Online or after-hours resources

Check to see if the plan provides access to a 24/7 nurse line or a medical help line for after-hours support or to help you decide whether you need to see a provider. Most plans offer online resources to help you easily find information about your care to support you in making the decisions that work best for you.

What is a value-based plan and why should I choose one if available in my county of residence?

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 certain measures about the quality of care they provide.

What type of plan should I select?

The PEBB Program offers three types of medical plans (value-based plans noted in bold):

Consumer-directed health plans (CDHPs)

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 other plans, and a higher deductible and a higher out-of-pocket limit. See Health plans with health savings accounts (HSAs).

• Kaiser Permanente NW¹ CDHP
• Kaiser Permanente WA² CDHP
• UMP CDHP

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 noncontracted provider.

• Kaiser Permanente NW¹ Classic
• Kaiser Permanente WA² Classic
• Kaiser Permanente WA² SoundChoice
• Kaiser Permanente WA² Value

Preferred provider organization (PPO) health plans

PPO’s 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.

• UMP Classic

• UMP Select

• UMP Plus–Puget Sound High Value Network
• UMP Plus–UW Medicine Accountable Care Network

¹ Kaiser Foundation Health Plan of the Northwest, offered only in Clark and Cowlitz counties in Washington, and select counties in Oregon.
² Kaiser Foundation Health Plan of Washington.