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2018 Open Enrollment Frequently Asked Questions

2019 Plan Changes for Active Members

  • Q. What are the changes for plan year 2019?
  • A.There are PPO deductible changes. There are no copayment changes under the PEBTF Custom HMO. The Prescription Drug Plan copayments change. Refer to the Open Enrollment newsletter for more information.

 

  • Q. What are the differences among the plan options for plan year 2019?
  • A. Detailed information is included in the Open Enrollment newsletter and on the PEBTF website. At a very high level, the PPOs have in-network deductibles on certain services and offer an out-of-network benefit.   The Choice PPO also has a PPO buy-up for employees hired on or after 8/1/2003.
  • The PEBTF Custom HMO is a network-benefit only and it offers a limited network of providers and facilities, while keeping the copayments low. You must choose an HMO-network primary care physician (PCP) at the time of enrollment. Your PCP will refer you to PEBTF Custom HMO network specialists.

 

  • Q. My provider does not participate with the plan I am considering for 2019. What should I do?
  • A. You would need to select another provider or select a different plan option available in your region. The PPO options have broad networks and the PEBTF Custom HMO has a limited network of providers. The PPOs also offer an out-of-network benefit but you will have higher out-of-pocket costs.

 

PPO Options

  • Q. What is the Choice PPO?
  • A. The Choice PPO is offered by Aetna. It has an in-network benefit and an out-of-network benefit. If you use in-network providers and facilities, you will have an annual in-network deductible of $400 single/$800 family on all services except preventive care, office visits and outpatient therapy copayments, emergency room and urgent care copayments. Also, employees hired on or after 8/1/2003, pay a biweekly PPO buy-up of $11.87 single/$30.64 family for the Choice PPO. Refer to the Open Enrollment newsletter for copayment amounts.  Also, there is separate deductible and coinsurance if you visit out-of-network providers.

 

  • Q. What is the Basic PPO?
  • A. The Basic PPO is offered by Highmark. It has an in-network benefit and an out-of-network benefit. If you use in-network providers and facilities, you will have an annual in-network deductible of $1,500 single/$3,000 family on all services except preventive care, office visit and outpatient therapy copayments, emergency room and urgent care copayments. Employees hired on or after 8/1/2003, do not pay a PPO buy-up for the Basic PPO. Also, there is separate deductible and coinsurance if you visit out-of-network providers.

 

  • Q. Are the Choice PPO and Basic PPO networks similar?
  • A. Yes, the networks are similar.   As always, you should take a look at each plan’s provider directories before making a decision for 2019. The PPOs also offer an out-of-network benefit but at higher out-of-pocket costs.

 

  • Q. Do both PPOs offer the same benefits?
  • A. Yes, the PEBTF Plan of Benefits is the same for both options. The medical policies of each plan may differ.

 

  • Q. Do copayments count toward the deductible?
  • A. No, copayments are separate.

 

  • Q. Do non-covered services count toward the deductible?
  • A. No, the service has to be medically necessary and covered under the plan.

 

  • Q. How does the family deductible work?
  • A. Each individual must satisfy his/her individual deductible before the PPO pays at 100% for those services subject to the deductible. For a family, the PEBTF limits the amount a family would pay in deductibles to $800 in-network/$1,600 out-of-network under the Choice PPO and $3,000 in-network/$6,000 out-of-network under the Basic PPO. So, no matter the size of the family, you would only be responsible for paying the family deductible. Members on a family contract would, at most, be responsible for the individual deductible until the family deductible is met.

 

  • Q. So does this mean that under the PPO options, I won’t have to pay the deductible if I just have office visits?
  • A. Correct, you will only pay the office visit copayment. Also, preventive care is covered 100%.

 

  • Q. Is it an annual deductible?
  • A. Yes. Each year you would have to satisfy the annual deductible before the plan pays 100% for those services subject to the deductible.

 

  • Q. What deductible would I pay if I am an Active employee and the only dependent on my Active policy is Medicare eligible?
  • A. You would pay the family deductible since your Medicare dependent would have primary coverage through the PEBTF and their Medicare plan would be secondary. If your Medicare eligible dependent is enrolled in a Medicare plan, they would be responsible for any deductibles that would apply to their plan

 

  • Q. Does the amount paid toward the in-network deductible apply to the out-of-network deductible?
  • A. No, the in-network deductible is separate from the out-of-network deductible.

 

  • Q. Do the copayments and deductibles apply to the medical out-of-pocket maximum?
  • A. The deductible applies to the medical out-of-pocket maximum however the copayments do not. The deductible and copayments apply to the Affordable Care Act combined out-of-pocket maximum.

 

  • Q. If I have a procedure done at an in-network facility and a non-participating provider administers anesthesiology or reads my x-ray, will I be responsible for the out-of-network deductible and coinsurance for their services?
  • A. No, if you would only be responsible for the in-network deductible.

 

  • Q. Do Mental Health services apply towards the deductible?
  • A. Yes, all Mental Health services except for the copayments apply toward the deductible.

 

  • Q. What if I get sick when traveling out of the country?
  • A. Emergency care is covered under all plan options, regardless of where you are. Services must be medically necessary to be covered. You should contact the plan to verify what is considered medically necessary. You may have to pay for the services and then submit a claim to the medical plan.

 

  • Q. Where do I find the list of preventive services?
  • A. Use this link to did the list of preventive services covered without a copay or deductibe: Preventive Benefits.

 

PEBTF Custom HMO

  • Q. What is the PEBTF Custom HMO?
  • A. The PEBTF Custom HMO is offered regionally to members who live in Pennsylvania. Aetna and Geisinger are the plans that are offered. Please refer to the map in the Open Enrollment newsletter. The PEBTF Custom HMO has an in-network benefit only. You must pick a network Primary Care Physician (PCP) at the time of enrollment. Your PCP will refer you to network specialists and other providers. You pay low copayments and there is no in-network deductible. The PEBTF Custom HMO has a limited network so it is very important that you review the plan’s provider directory to make sure the doctors and hospitals you want are in the network.

 

  • Q. What is a limited network?
  • A. The limited network is a smaller group of providers and facilities. The limited network allows the PEBTF to offer low copayments in the PEBTF Custom HMO option. It is very important that you take a look at the plan’s network before choosing this option.

 

  • Q. Why does the PEBTF Custom HMO have a limited network?
  • A. By offering a smaller network under the PEBTF Custom HMO, we are able to offer the low HMO copayments and no deductible.  

 

  • Q. Do I have to pick a primary care physician (PCP) if I enroll in the PEBTF Custom HMO?
  • A. Yes, you must choose a PCP who is part of the plan’s network. If it is a new PCP for you, make sure that doctor is accepting new patients. Include that PCP’s name on your enrollment which must be done by November 2. Your PCP will refer you to network specialists and other providers.

 

  • Q. Can I enroll in the PEBTF Custom HMO if I have a dependent that lives outside of my area?
  • A. We cannot prevent you from enrolling in the PEBTF Custom HMO. But, we caution you that if your dependent lives outside of the HMO’s service area, he or she will only be covered for emergency/urgent care. Your dependent would have to come back to the plan’s service area to get any other medical services from a network provider. The PEBTF Custom HMO does not cover services obtained by an out-of-network provider.

 

  • Q. What if I have an emergency?
  • A. Get to the nearest emergency room. Emergency care is covered under the PEBTF Custom HMO no matter where you are.

 

  • Q. If my PEBTF Custom HMO PCP refers me to an out-of-network facility or hospital, would the services be covered?
  • A. No, the PEBTF Custom HMOs do not have an out-of-network benefit, the costs would be 100% your responsibility unless the plan pre-authorized that care.

 

  • Q. If I am currently in a PPO and switch to the Custom HMO, do I need to request referrals to my specialists who are accepting the Custom HMO plan?
  • A. Yes, if you enroll in the Custom HMO you will need to request referrals for all of your specialists who are in-network with the Custom HMO offered in your region.

 

  • Q. If I have ongoing care under the Custom HMO, do I need a referral for each appointment with that specific specialist or is the referral good for a year?
  • A. Your PCP will indicate how many approved visits on the referral and what period of time it covers. Referrals can be good for up to one year based on what you PCP specifies.

 

  • Q. What if I get sick when traveling out of the country?
  • A. . Emergency care is covered under all plan options, regardless of where you are. Services must be medically necessary to be covered. You should contact the plan to verify what is considered medically necessary. You may have to pay for the services and then submit a claim to the medical plan.

 

  • Q. Where do I find the list of preventive services?
  • A. Use this link to find the list of preventive services covered without a copay or deductible: Preventive Benefits.

 

Enrollment

  • Q. When is Open Enrollment?
  • A. October 15 through November 2, 2018.

 

  • Q. What do I need to do during Open Enrollment?
  • A. You must review the plan options and provider networks of the options you are considering. If you want to make a plan change follow the directions in the Open Enrollment newsletter/www.pebtf.org on how to complete enrollment. Enrollment must be completed by the November 2nd deadline.

 

  • Q. Can I change plans during the year?
  • A. The only way you can change plans during the year is by having a qualifying life event. Examples of qualifying life events are marriage, divorce or reduction of hours.

 

  • Q. How do I make a medical plan selection during Open Enrollment?
  • A. When you are ready to select a medical plan, you can use employee self-service at www.myWorkplace.state.pa.us beginning October 15, 2018 or contact commonwealth’s HR Service Center which is available at 1-866-377-2672. You can call your local HR office if your agency is not supported by the commonwealth’s HR Service Center.

  • All online transactions must be completed and all forms must be postmarked by Friday, November 2.

 

Benefit Design

  • Q. What do I pay for lab work?
  • A. See below for the differences between the PPO and PEBTF Custom HMO.
  • PPO Options:
  • It depends on where the lab work is processed, as follows:
  • In-Network Providers
  • If your lab test is done at Quest Diagnostics or LabCorp, it is covered 100% and there is no deductible applied. You will pay a $30 lab copayment for any lab tests not performed by Quest Diagnostics or LabCorp.
  • Out-of-Network Providers
  • If you visit an out-of-network provider, you are responsible for paying the deductible, coinsurance and the difference between the provider’s charge and the plan allowance.
  • PEBTF Custom HMO:
  • If you select the HMO and the lab work was done at a network provider with the required referral, the lab work will be covered at 100%. If you go to an out-of-network provider, you would be responsible for 100% of the charges because the HMO does not have an out-of-network benefit.

 

  • Q. Does the deductible apply for other diagnostic tests?
  • A. If you select the Choice PPO or the Basic PPO, all diagnostic tests are subject to the deductible and will be covered 100% after the deductible is met. If you visit an out-of-network provider, you are responsible for the out-of-network deductible, coinsurance and the difference between the provider’s charge and the plan allowance.
  • If you select the HMO and the diagnostic test was done at a network provider with the required referral, the diagnostic test will be covered at 100%.

 

  • Q. What is my copayment if I go to a Minute Clinic or a similar type of urgent care provider in a drug store/grocery store?
  • A. Your copayment would be the PCP copayment – $20 for the PPO plans and $5 for the PEBTF Custom HMO plans. If you go to an urgent care facility, for example Patient First, which is able to provide more services such as X-rays, your copayment would be $50 under all plans. You must check if the urgent care provider is in-network. Remember, under the Custom HMO, there is no out-of-network coverage.

 

  • Q. If I have blood tests while I am at an Urgent Care facility or Emergency Room, will I be responsible for the additional $30 lab copayment?
  • A. No, you would only be responsible for the Urgent Care or ER copayment. If you are admitted to the hospital from the emergency room, the copayment would be waived and you would be responsible for the deductible for the inpatient stay.

 

  • Q. If my PCP refers me to an Urgent Care facility, is the Urgent Care copayment waived?
  • A. No, you would be responsible for the Urgent Care copayment.

 

  • Q. If I go to the Emergency Room and they keep me for observation, is my copayment waived?
  • A. No, if you are kept for observation you are not admitted to the hospital so you would still be responsible for the copayment.

 

  • Q. If I go to an Urgent Care facility and they refer me to the Emergency Room, am I responsible for both copayments?
  • A. Yes, you will be responsible for both copayments, however if you are admitted to the hospital from the Emergency Room, the copayment will be waived.

 

  • Q. What are the in-network pharmacies and who are they?
  • A. They are the same pharmacies as you have now.  Example CVS stores, Rite Aid stores, Giant Eagle and many independent pharmacies.

 

  • Q. Do non-covered services go towards the deductible?
  • A. No, the cost of non-covered services does not go towards the deductible.

 

  • Q. Does the deductible apply to my Cpap supplies?
  • A. No, there are no changes to the DME (Durable Medical Equipment) benefit.

 

  • Q. If I have my annual OBGYN exam and they do the Pap Test, will the Pap Test go towards the deductible?
  • A. No, this service is part of the preventive schedule and covered at 100%, not subject to the deductible.

 

  • Q. If I have a preventive colonoscopy and the doctor finds a polyp, will the deductible apply to the diagnostic testing of the polyp?
  • A. Yes, the deductible will apply to the diagnostic testing of the polyp.

 

Get Healthy

  • Q. Are there changes to the Get Healthy Program?
  • A. The wellness screenings continue to be offered in 2018. Only the employee has to complete a wellness screening by December 31, 2018 to save money.

 

  • Q. How do I request a Physician’s Results Form?
  • A. Complete the registration process on the Quest Diagnostics website. To access the Quest site, go to www.pebtf.org and click on the Get Healthy logo. Follow the instructions on the website. If you cannot go online, please contact Quest Diagnostics at 1-855-623-9355 to request the Physician’s Results Form.

 

  • Q. How do I make an appointment for a Quest Diagnostics Patient Service Center?
  • A. To make an appointment online, follow the instructions below
  • Register Online:
  • 1. Go to www.pebtf.org on or after August 1.
  • 2. Click on the Get Healthy logo on the left side of the home page.
  • 3. Follow the instructions on the website to register for a wellness screening.

 

  • Q. I am a new employee; will I be charged the Get Healthy surcharge since I was not eligible for coverage in 2017?
  • A. You will be given 45 days from the date you enrolled in your benefits to complete the Get Healthy Screening. Once you complete the Get Healthy Screening within that 45 day period, you will be reimbursed retroactive to your effective date of coverage.

 

  • Q. If I do not elect benefits until January 1, 2019 will I be charged the Get Healthy Surcharge?
  • A. You will be given 45 days from the date you enrolled in your benefits to complete the Get Healthy Screening. Once you complete the Get Healthy Screening within that 45 day period, you will be reimbursed retroactive to your effective date of coverage.

 

Miscellaneous

  • Q. Where do I find the networks of providers?
  • A. The PEBTF website, www.pebtf.org, links to the medical plans websites. Click on 2018 Open Enrollment to get started.  

 

  • Q. I live out-of-state. What plans are available?
  • A. The Choice PPO or the Basic PPO.

 

  • Q. What if I get sick when I am traveling out of the country?
  • A. Emergency care is covered under all plan options, regardless of where you are. Services must be medically necessary to be covered. You should contact the plan to verify what is considered medically necessary. You may have to pay for the services and then submit a claim to the medical plan.

 

  • Q. Will I get a new medical plan ID card?
  • A. Yes. If you change medical plans you will get a new ID card. Present the new ID card to your doctor in 2019. You will not get a new prescription drug ID card even though there are copayment changes under that plan.

 

  • Q. Where can I find a list of covered immunizations?
  • A. They are listed on the PEBTF website and in the Summary Plan Description. The PEBTF follows the CDC’s Advisory Committee on Immunization Practices (ACIP) guidelines.

 

  • Q. Are there changes to the prescription drug plan?
  • A. Yes, there are copayment changes for 2019. As always, to save money ask your doctor to prescribe a generic drug.  

 

  • Q. Are there changes to my mental health and substance abuse benefits?
  • A. The covered benefits remain the same. If you are enrolled in the PPO, you will have a $20 outpatient mental health copayment and you continue to have an out-of-network benefit. If you are enrolled in the PEBTF Custom HMO, your outpatient mental health copayment will be $5 and you will not have an out-of-network benefit. All out-of-pocket costs count toward the combined out-of-pocket maximum under the medical plan.

 

  • Q. Are there changes to vision, dental and hearing aid benefits?
  • A. No. Also, Optum continues to provide the mental health and substance abuse benefit and DMEnsion continues to provide the durable medical equipment (DME), prosthetics, orthotics, medical and diabetic supply benefit.

 

  • Q. Is there a webinar that I may view?
  • A. Yes, you may visit www.pebtf.org and click on the 2018 Open Enrollment button. You will find a recorded webinar under the Webinars button.

 

  • Updated 09-19-2018