General Medical Plan FAQ's
Where can I find more detailed information on coverage levels of all offered plans?- You can go to the Decision Tools tab under the Retiree Open Enrollment website and click on 2008 Open Enrollment Medical Plans Comparison Chart.
- What is coinsurance?
- Coinsurance is a cost-sharing feature by which the Plan pays a percentage of the covered charge and the covered member pays the balance.
- What does the term "negotiated rate" refer to?
- Negotiated rates are the rates physicians agree to charge through their contract with the insurance provider. Negotiated rates apply to in-network charges.
- Under the out-of-network provision under the UHC and CIGNA Premier PPO Plans, what does eligible expense mean?
- Eligible expenses are charges for covered health services that are provided while the Plan is in effect. For out-of-network benefits, the claims administrator uses selected data resources which, in their judgment, represent competitive fees in that geographic area or negotiated rates agreed to by the out-of-network provider and the Claims Administrator or one of its vendors, affiliates or subcontractors. The amount above the eligible expense would not be covered under the plan and would not apply to your out-of-pocket maximum. For example, if you were to see a non-network provider and the eligible charge was $50 but the provider charged $75, you would be responsible for the difference in cost between the eligible expense ($50) and the provider's charge ($75), as well as any co-insurance.
- What charges are considered out-of-pocket expenses under the PPO Plans?
- Out-of-pocket expenses include deductibles (if applicable) and coinsurance. Prescription drug costs and amounts above eligible expenses are not applied towards your out-of-pocket maximum. In addition, out-of-network behavioral health care costs do not apply to the out-of-pocket maximum.
- Where can I get a list of in-network providers for the medical plans?
- See the Resources and/or Contacts page or you may also call the Health, Benefits, and Employee Services Customer Service Center at 844-HBES (4237) for copies.
- Under the PPO plans, if I have an emergency and go to an out-of-network emergency room, what level of reimbursement will I receive?
- If the facts of the case suggest that it was indeed an emergency (deep cut, heart attack, stroke or other such life/limb threatening situations), you would be reimbursed at the in-network level of benefit.
- Am I required to obtain a referral from my primary care physician (PCP) to to see a specialist?
- The only plan that may require referrals from a PCP is Kaiser.
- How do I handle getting more ID cards?
- New plan enrollees will receive new ID cards. After January 1, 2008, you should be able to go to myuhc.com or mycigna.com to request or print off ID cards.
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- Does the well exam 100% coverage only consist of the exam?
- The 100% coverage (in-network) for the well exam includes the exam and certain lab work associated with the exam. Refer to your Summary Plan Description for your preventive care benefit.
- How do I know how much an emergency room visit will cost?
- You can use the treatment cost estimator under myuhc.com or mycigna.com but it will only give you an approximate idea and should only be used as a guide. You can also use the Medical Plan Selection Tool on Sandia's OE web site for information.
- What are the rates based on under the Medical Plan Selection Tool?
- In-network uses negotiated rates, and out of network uses usual and customary rates.
- Under the UHC and CIGNA Premier PPO plans, if the co-pays do not go towards the deductible, how do you meet the deductible?
- Through coinsurance you pay.
- If I transfer from Lovelace to Presbyterian (or vice versa) how are my prescriptions handled?
- You will need a new prescription rewritten by your new physician.
- Under the PPO plans, what happens when I hit my out-of-pocket maximum?
- You will not pay any further co-insurance payments for the remainder of the calendar year, but you will continue paying co pays (if applicable). However, for the non-Medicare plans, please realize out-of-pocket maximums do not cross-apply. Therefore, if you hit your in-network out-of-pocket maximum and seek services out-of-network, you will have to pay the applicable benefit.
- What happens if I am enrolled in the Cigna In-Network Plan and am on vacation and an urgent matter comes up? Is that covered?
- Yes, urgent care and emergency care is covered in-network. Follow-up care is covered if you see an in-network provider.
- Why are co-pays not allowed towards the out-of-pocket max?
- This is typical in a copay/coinsurance plan.
- Does UHC have a list of the best doctors in the US?
- UHC has a nationwide preferred physician network under their UnitedHealth Premium physician lookup included under myuhc.com. You may also want to try www.healthgrades.com to view report cards on physicians.
- How do I know which are in-network lab and x-ray facilities?
- You may view online (the most current/accurate data) through myuhc.com or mycigna.com.
- If I am hospitalized under the UHC or CIGNA Premier PPO Plan for approximately $47,000 bill what should I expect to pay out of my pocket?
- If it is in-network, your out-of-pocket maximum will be $1,750. The out-of-pocket maximum includes the deductible amount.
- What if my doctor orders six or seven lab tests, do I pay a co-pay for each test?
- Under UHC and Cigna Premier PPO Plans you will pay a coinsurance for the entire battery of tests. Under the Cigna In-Network and Kaiser Plans you will pay nothing for lab and radiology.
- Under the UHC or CIGNA PPO Plan, if there are only two in my family, myself and spouse, do we have the individual deductible or the family?
- Your deductible is double the individual.
Medicare Plan FAQ's
- How can I find out if my current doctor is in a Medicare Advantage Plan such as the Lovelace Senior Plan or the Presbyterian MediCare PPO?
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The health providers in each plan's network can change at any time. The best way to determine whether your provider is in either the Lovelace Senior Plan or the Presbyterian MediCare PPO is by calling member services. For the latest provider listing for the Lovelace Senior Plan call the Lovelace Health Plan at (505) 262-3757 or ask your doctor's office if he/she participates in the Lovelace Senior Plan. For the latest provider listing for the Presbyterian MediCare PPO, call the Presbyterian Health Plan at (505) 923-6060 or ask your doctor's office if he/she participates in the Presbyterian MediCare PPO.
- Can I change Sandia-sponsored medical plans mid-year?
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You can change you medical plan only during the annual Open Enrollment period that is held by Sandia in the fall or if you move out of New Mexico or California and you were a participant in the Kaiser Senior Plan, Lovelace Senior Plan, or the Presbyterian MediCare PPO.
- I am in the United Health Care Premier PPO, can I cover my Class II dependent under the Presbyterian MediCare PPO?
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Class II dependents are not eligible for the Presbyterian MediCare PPO, Lovelace Senior Plan, or the CIGNA In-Network Plan.
- Why did I receive an Explanation of Benefits (EOB) that says I owe money when I paid my portion at the time of service?
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The EOB/Health Statement is not a bill. The statement is for your information only. Your provider will bill you if there is a balance due.
- Do I need to buy Medicare Part D for prescription drug coverage?
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You are not required to purchase the Medicare Part D for prescription drug coverage if you have coverage through a Sandia-sponsored health care plan (CIGNA Senior Premier PPO or UnitedHealthcare Senior Premier PPO). The prescription drug coverage through these two plans is better than the Medicare Part D. You are not eligible to enroll in a Medicare Part D plan if you are enrolled in the Sandia group Medicare Advantage Plans (Kaiser Senior Plan, Lovelace Senior Plan, Presbyterian MediCare PPO) as you already have Medicare Part D through the group plan.
- Can I see a provider who is not in the network?
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If you are in the Kaiser Senior Plan or the Lovelace Senior Plan, you must pay for those services yourself (unless the out-of-network care is directed by the health plan). Neither plan will pay for those services. The Presbyterian MediCare PPO does have a provision for you to see out-of-network providers.
- What coverage do I have if I am in an accident while traveling outside the state?
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You are provided worldwide coverage for urgent and emergency care at the in-network benefit level if you were enrolled in a Sandia-sponsored medical plan including Kaiser Senior Plan, Lovelace Senior Plan, and the Presbyterian MediCare PPO. You may have to pay for the service upfront and then file your claims for reimbursement.
Are you having trouble finding the answer to your question?
You can submit questions to the New Get Answers system, which provides interactive self-help customer service on the web. The system allows you to send your question and receive an answer through email. Your question and answer will be stored and available for future use by yourself and others that may have that same question. Check out Get Answers @ hbeupdate.custhelp.com
