Health Plan Design

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 coverage for medical and pharmacy benefits (at no additional cost). This plan has a lower deductible and a higher monthly premium.

  • This plan design only covers out-of-network benefits for emergency and urgent care services.
  • Review the Comparison of Health and Pharmacy Benefits (available in the Forms & Resources section below) to determine which plan design will best meet your needs.

For detailed information, review the Certificate of Coverage (available in the Forms & Resources section below).

Provider Network

This plan design only covers out-of-network benefits for emergency and urgent care services. For this reason, use the Health Plan Search (available in the Forms & Resources section below) to help you select a health insurance plan carrier that will provide services in the county that you would like to receive them 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:

  • Premium 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% at in-network providers, even if you have not met the deductible. A link to the preventive care services, as identified by the Patient Protection and Affordable Care Act, is available in the Forms & Resources section below.

Non-preventive Care

Non-preventive care received in-network 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)

Non-preventive care such as lab tests, x-rays and/or 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 deductible within the family deductible. When an individual within a family meets the annual individual $250 deductible, the health insurance carrier will begin to cover services for that individual according to the schedule of benefits (available in the Forms and Resources section below). This deductible applies to medical services only. There is not a deductible for pharmacy benefits under the Health Plan design.

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 pharmacy benefits 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 urgent care. Contact your health insurance carrier immediately if you seek out-of-network emergency or urgent care services.

Pharmacy Benefits

Pharmacy benefits are included in all health plan designs at no additional cost, and are administered by Navitus Health Solutions. In the left hand menu, click “Pharmacy Benefits” to learn more.

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 and Preventive Dental” to learn more.

Benefit Premiums

For State Group Health Insurance premiums review the Benefit Premiums web page.

Forms & Resources

Plan Administrators

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.

Updated: 05/29/2024