Plan Design Overview

The Health Plan allows you to choose from a variety of local health insurance plan carriers that offer the same Uniform Benefits that include medical and prescription drug coverage (at no additional cost). This plan has a lower deductible and lower out-of-pocket limits, but a higher monthly premium.

  • Compare the Health Plan to the other plan designs to determine if it will meet your needs.
  • This plan design only covers out-of-network benefits for emergency and urgent care services.

For detailed information, review the Certificate of Coverage.

Provider Network

This plan design only covers out-of-network benefits for emergency and urgent care services. For this reason, it is important to use the Health Plan Map to help select the health insurance carrier that includes the providers and hospitals in the preferred county that services will be received in.

Coverage

In-Network Coverage

Uniform Benefits

Uniform Benefits refers to the schedule of benefits provided by each health insurance plan carrier. The purpose of Uniform Benefits is to help manage the rising cost of health insurance and simplify your selection of a health plan. Because all health insurance plan carriers administer the same schedule of benefits, you can decide which plan to select based on:

  • Cost
  • Quality and member satisfaction
  • Provider network
  • Referral policies

Uniform Benefits does not mean that all plans will treat all services in an identical manner. Treatment will vary depending on the needs of the patient, the providers involved and the managed care policies and procedures of each health insurance plan carrier.

Preventive Care

Routine preventive care will be covered at 100%, even if you have not met the deductible. Here is a list of preventive care services, as identified by the Patient Protection and Affordable Care Act.

Non-preventive Care

Non-preventive care is subject to copays (not the deductible). See the Guide to Office Visit Copays for more information. For non-preventive care, you will pay:

  • $15 copay for office visits
  • $25 copay for specialty office visits (includes specialty providers, urgent care, vision exam)

Other non-preventive care (e.g., lab tests, x-rays, inpatient care) will require you to meet your deductible first. Once you meet the deductible, you will pay either an office visit copay (flat dollar amount) or coinsurance (a percentage) on other medically necessary care until you reach the annual out-of-pocket limit.

Deductible: $250 Individual/ $500 Family

The Health Plan design has an embedded deductible. This means that there is an individual within a family deductible. If an individual within a family plan meets the annual individual $250 deductible, the Uniform Benefits will take effect for that individual. This deductible applies to medical services only; there is no deductible for prescription drug coverage under the Health Plan.

Once the deductible has been met, you will pay:

  • $15 copay for office visits
  • $25 copay for specialty office visits (includes specialty providers, urgent care, vision exam)
  • $75 copay for emergency room visits (waived, if admitted). Deductible and coinsurance applies to services beyond the copay.
  • 10% coinsurance on most services except for office visits
Out-of-Pocket Limit: $1,250 Individual/ $2,500 Family

This annual out-of-pocket limit applies to medical services only. There is a separate annual out-of-pocket limit for prescription drug coverage under the Health Plan design. Once you reach your out-of-pocket limit, the plan pays 100% of most covered benefits for the remainder of the calendar year.

Out-of-Network Coverage

This plan design only covers out-of-network services for emergency and/or urgent care. Contact your health plan immediately if you seek out-of-network emergency and/or urgent care services.

Pharmacy Benefits

Prescription drug coverage is included in all health plan designs at no additional cost and is provided by Navitus Health Solutions. There is no deductible for prescription drug coverage under the Health Plan design.

You will be required to pay either a copay or coinsurance when you buy prescription drugs which is determined by the level of the drug. All covered prescription drugs fall into one of four cost-sharing levels: Level 1 for most generic drugs and Levels 2, 3 and 4 for most brand-name drugs.

To determine what you would pay for prescription drugs, see the Comparison of Pharmacy Benefits. For detailed information regarding pharmacy benefits, review the Certificate of Coverage.

Uniform Dental Benefits

Uniform Dental Benefits may be added to your health insurance coverage for a minimal cost. In the left hand menu, click “Dental & Vision Insurance” then “Uniform Dental Benefits” to learn more.

Benefit Premiums

For State Group Health Insurance premiums, see the Premiums page.

Forms & Resources

For all State Group Health Insurance forms and resources, click here.


last updated: 04/18/2019

Every effort has been made to ensure this information is current and correct. Information on this page does not guarantee enrollment, benefits and/or the ability to make changes to your benefits.