Things to think about when choosing a medical plan
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 employment 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, or change jobs to another employment location and your plan is no longer available, you must change your plan. If you do not, the SEBB Program will enroll you in one. You must report your new address and any plan change request to your payroll or benefits office no later than 60 days after you move.
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).
How do I compare the plans?
All SEBB medical plans cover the same basic health care services. They vary in other ways, such as provider networks, premiums, out-of-pocket costs, and drug formularies. Below are tools to help you choose the plan that's right for you.
Plan differences to consider
- Your provider
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.
- 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. 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 Behavioral services by plan and 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
All SEBB medical plans coordinate benefit payments with other group plans, 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.
SEBB medical, dental, and vision coverage is limited to a single enrollment per individual. You cannot enroll in health plans under both the SEBB and PEBB Programs. If you are enrolled in both SEBB and PEBB health plans, the SEBB Program or PEBB Program will automatically enroll or disenroll you as described in WAC 182-31-070.
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. View plan costs for school employees or SEBB Continuation Coverage subscribers.
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.
- Coinsurance or copays
When you receive care, some plans require you to pay a percentage of an allowed fee, called coinsurance. Other plans require you to pay a fixed amount, called a copay. 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 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' benefits booklet for specifics.
- 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.
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 four types of medical plans: high-deductible health plans (HDHP), managed care plans, and preferred provider organization (PPO) plans. In addition, some plans are also value-based.
- Value-based plans
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.
- Managed-care plans
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*
- Premera HMO*
- 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 Summit PPO 1
- Kaiser Permanente WA Options Summit PPO 2
- Kaiser Permanente WA Options Summit PPO 3
- Premera High PPO
- Premera Standard PPO
- UMP Achieve 1 (administered by Regence BlueShield)
- UMP Achieve 2 (administered by Regence BlueShield)
- UMP Plus–Puget Sound High Value Network (administered by Regence BlueShield)*
- UMP Plus–UW Medicine Accountable Care Network (administered by Regence BlueShield)*
- 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. If you enroll in an HDHP, you can also enroll in a Limited Purpose FSA, which allows you to set aside pretax money to pay for dental and vision expenses. See Health plans with a health savings accounts and the flexible spending arrangements webpages for more information.
- UMP High Deductible (administered by Regence BlueShield)