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 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.

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 and whether you and any eligible dependents you wish to enroll are enrolled in Medicare Part A and Part B. 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).

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 (non-Medicare) (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 personnel, payroll, or benefits office no later than 60 days after your move.

How do I compare the plans?

All 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, premiums, and drug formularies. Get a side-by-side comparison of common medical benefits and costs for services.

• Medical benefits comparison tool (online)

Medical plan benefits comparison

• 2020 (printable)

Medicare plan benefits comparison

• 2020 (printable)

Plan differences to consider

When choosing a plan to best meet your needs, here are some things to consider:

Premiums

Premiums vary by plan. A higher premium doesn’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 premiums than the value plans. However, classic plans may have lower annual deductible, copays, or coinsurance costs. See plan costs to see premiums for all PEBB medical plans.

Deductibles

Most medical plans, except Premera Blue Cross Medicare Supplement Plan F, and Kaiser Permanente NW’s and Kaiser Permanente WA’s Medicare Advantage plans, require you to pay an annual deductible before the plan pays for covered services. UMP Classic, and Kaiser Permanente WA Classic, Value, and SoundChoice plans also have 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.

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

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, and Kaiser Permanente WA Classic, Value, and SoundChoice 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 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 nonnetwork providers.
• Prescription drug deductible and prescription-drug coinsurance (UMP Classic and Kaiser Permanente WA non-Medicare plans 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.

Your provider

If you have a long-term relationship with your doctor or health care provider, you should verify whether he or she is 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 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.  For more information, see Engrossed Substitute House Bill 1099 (Brennen’s Law).

Paperwork

In general, PEBB 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 state-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 plans (except Kaiser Permanente WA Medicare Advantage and Premera Blue Cross Medicare Supplement Plan F) coordinate benefit payments with other group plans, Medicaid, and Medicare. This is called coordination of benefits. This coordination ensures benefit costs are more fairly distributed when a person is covered by more than one plan. However, the amount your PEBB medical 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 medical plans that cover prescription drugs will not coordinate prescription-drug coverage with Medicare Part D. All PEBB medical 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 retiree insurance coverage.

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.

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?

Your options are limited to plans that are available in your county and whether you or your covered dependents are enrolled in Medicare Part A and Part B.  The PEBB Program offers three types of medical plans.

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).

Managed-care plans

Managed-care plans may require you to select a primary care provider within its network to fulfill or coordinate all of your health care needs. You can change providers at any time, for any reason within the contracted network. The plan may not pay benefits if you see a noncontracted provider.

Preferred provider organization (PPO) 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.

Medical plan options

In general, PEBB 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

For members enrolled in Medicare Part A and B. Value-based plans noted in bold.

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

Non-Medicare options

For members not eligible for Medicare or enrolled in Part A only. Value-based plans noted in bold.

Consumer-directed health plans (CDHPs)

• Kaiser Permanente NW CDHP¹
• Kaiser Permanente WA CDHP²
• UMP CDHP, administered by Regence BlueShield

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

Managed-care plans

(Note: At least one family member must not be enrolled in Medicare Part A and Part B.)

• Kaiser Permanente NW Classic¹
• Kaiser Permanente WA Classic²
• Kaiser Permanente WA SoundChoice²
• Kaiser Permanente WA Value²

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

Preferred-provider plans

• UMP Classic, administered by Regence BlueShield
• UMP Plus—Puget Sound High Value Network, administered by Regence BlueShield (Note: Not available to retirees enrolled in Medicare Part A and Part B.)
• UMP Plus—UW Medicine Accountable Care Network, administered by Regence BlueShield (Note: Not available to retirees enrolled in Medicare Part A and Part B.)

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

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

 What do I need to know about the Medicare Advantage and Medicare Supplement plans?

Medicare Advantage plans

These plans are available from Kaiser Permanente NW and Kaiser Permanente WA, but are not available in every county. If you or a covered dependent are enrolled in Medicare Part A and Part B and you choose Kaiser Permanente NW or Kaiser Permanente WA, you must enroll in the Medicare Advantage plan if they offer it in your county.

These plans contract with Medicare to provide all Medicare-covered benefits; however, most also cover the deductibles, coinsurance, and additional benefits not covered by Medicare. Neither the health plan nor Medicare will pay for services received outside of the plan’s network except for authorized referrals and emergency care.

Kaiser Permanente WA also offers an Original Medicare plan for Medicare retirees who live in a county not served by the Kaiser Permanente WA Medicare Advantage plan. Your enrollment in a Medicare Advantage plan is effective the first of the month after the PEBB Program receives your enrollment form, or effective as of your enrollment in both Medicare Parts A and B, whichever event occurs later, and may not be the same as your retirement date.

Medicare Supplement Plan G, administered by Premera Blue Cross

This plan allows the use of any Medicare contracted physician or hospital nationwide. The plan is designed to supplement your Medicare coverage by reducing your out-of-pocket expenses and providing additional benefits. It pays some Medicare deductibles and coinsurances, but primarily supplements only those services covered by Medicare.

In Medicare Supplement Plan G, benefits such as vision, hearing exams, and routine physical exams may have limited coverage or may not be covered at all. If you select Medicare Supplement Plan G, any enrolled members who are not entitled to Medicare will be enrolled in UMP Classic.

Medicare Supplement Plan F does not include prescription drug coverage. If you select this plan, you may have to enroll in Medicare Part D to get your prescriptions, unless you have other creditable prescription drug coverage. Visit Medicare Supplement Plan G for more information.