Frequently Asked Questions

Our health insurance plans typically cover preventive care, doctor visits, emergency care, hospital stays, and prescription medications. The specific coverage depends on your plan type. Preventive services like annual check-ups, vaccinations, and screenings are covered at 100% with no cost-sharing when provided by in-network providers. For a detailed breakdown of your specific coverage, please log in to your member portal or refer to your Summary of Benefits and Coverage document.

To find an in-network doctor or healthcare facility, you can:

1. Use our online provider directory on the member portal
2. Call the member services number on the back of your insurance card
3. Use our mobile app to search providers near your location

Remember that receiving care from in-network providers will result in lower out-of-pocket costs. Our network is regularly updated, so we recommend verifying a provider's network status before scheduling appointments.

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. For example, with a $2,000 deductible, you pay the first $2,000 of covered services yourself.

Copayment: A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. For example, you might pay $20 for a doctor visit or $10 for a prescription.

Coinsurance: Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20.

In most cases, in-network providers will submit claims directly to us on your behalf. If you need to submit a claim yourself (for out-of-network services or when the provider doesn't submit the claim):

1. Log in to your member portal and access the claims section
2. Complete the claim form (available for download on our website)
3. Attach any required documentation, including itemized bills and receipts
4. Submit the claim through the portal, by mail, or via our mobile app

Claims should be submitted within 12 months from the date of service. Processing typically takes 15-30 days from receipt of all required information.

The out-of-pocket maximum is the most you'll have to pay for covered services in a plan year. After you reach this amount, the insurance plan pays 100% for covered services. This limit includes deductibles, coinsurance, copayments, and other qualified medical expenses. Your specific out-of-pocket maximum depends on your plan and can be found in your plan documents or by logging into your member portal. For 2025, the Affordable Care Act sets the maximum out-of-pocket limit for marketplace plans at $9,450 for individual coverage and $18,900 for family coverage, but your plan's limit may be lower.

You can pay your monthly premium through several convenient methods:

1. Automatic payments from a checking/savings account or credit card
2. Online one-time payment through your member portal
3. By phone using our automated payment system
4. By mail with a check or money order
5. In person at one of our service centers

Premiums are typically due on the first of each month, with a grace period extending to the 15th. Setting up automatic payments is recommended to avoid any potential lapses in coverage.

Whether you need a referral depends on your specific plan type:

HMO Plans: Yes, you typically need a referral from your primary care physician (PCP) before seeing a specialist. Without a referral, the specialist visit may not be covered.

PPO Plans: Generally, you do not need a referral to see a specialist. However, seeing in-network specialists will result in lower out-of-pocket costs.

EPO Plans: Referrals are typically not required, but you must use providers within the plan's network for services to be covered (except in emergencies).

Always verify referral requirements by checking your plan documents or calling member services before scheduling specialist appointments.

Prior authorization (also called pre-authorization or pre-certification) is approval from your insurance company that a healthcare service, treatment plan, prescription drug, or durable medical equipment is medically necessary before you receive the service.

Services commonly requiring prior authorization include:
- Hospital admissions
- Outpatient surgeries
- Advanced imaging (MRI, CT scans, etc.)
- Certain medications
- Durable medical equipment
- Specialized treatments

Your healthcare provider typically handles the prior authorization process, but it's good practice to verify if authorization is needed before receiving services. Failure to obtain required prior authorization may result in reduced benefits or claim denial.

You can add dependents to your plan during:

1. Open Enrollment: The annual period when you can make changes to your health insurance plan.

2. Special Enrollment Period: If you experience a qualifying life event such as:
- Birth or adoption of a child
- Marriage
- Loss of other coverage
- Moving to a new coverage area

To add a dependent, log in to your member portal and select 'Update Coverage' or complete the dependent addition form available on our website. You'll need to provide documentation (birth certificate, marriage certificate, etc.) and submit it within 30 days of the qualifying event. New dependents' coverage typically begins on the first day of the month following the event or application.

Our prescription drug coverage is organized in tiers that determine your cost-sharing amount:

Tier 1: Generic medications (lowest copay)
Tier 2: Preferred brand-name medications
Tier 3: Non-preferred brand-name medications
Tier 4: Specialty medications (highest copay/coinsurance)

Benefits include:
- Access to a wide network of pharmacies
- Mail-order pharmacy option for maintenance medications (often at reduced cost)
- Prescription drug formulary (list of covered medications)
- Medication management programs

Some medications may require prior authorization, step therapy, or quantity limits. Check your plan documents or our online drug formulary to verify coverage for specific medications.

An Explanation of Benefits (EOB) is a statement that explains what costs your health insurance plan will cover for healthcare services. To access your EOBs:

1. Online: Log in to your member portal and navigate to the 'Claims & EOBs' section
2. Mobile App: Check the claims section in our mobile application
3. Mail: EOBs are typically mailed after claims processing unless you've opted for paperless delivery

EOBs include information about the service provided, the amount billed, the amount covered by insurance, and your financial responsibility. They are not bills but help you understand your coverage and verify that you're being billed correctly by your provider.

Under the Affordable Care Act, our plans cover a wide range of preventive services at no cost to you (no copayment, coinsurance, or deductible) when provided by an in-network provider. These include:

For all adults:
- Annual wellness exams
- Blood pressure, cholesterol, and diabetes screenings
- Immunizations and vaccines
- Depression screenings

For women:
- Well-woman visits
- Mammograms
- Cervical cancer screenings
- Contraception and contraceptive counseling

For children:
- Well-child visits
- Vision and hearing screenings
- Developmental assessments
- Vaccinations

For these services to be covered at 100%, they must be billed as preventive by your provider and not be associated with an existing condition or ongoing treatment.

HMO (Health Maintenance Organization):
- Requires you to choose a primary care physician (PCP)
- Requires referrals from your PCP to see specialists
- Only covers in-network care (except in emergencies)
- Generally offers lower premiums and out-of-pocket costs

PPO (Preferred Provider Organization):
- No need to select a PCP
- No referrals needed to see specialists
- Covers both in-network and out-of-network care (though you'll pay more for out-of-network)
- Generally offers more flexibility but higher premiums

EPO (Exclusive Provider Organization):
- Typically doesn't require a PCP or referrals
- Only covers in-network care (except in emergencies)
- Often combines the flexibility of a PPO with the network limitations and lower costs of an HMO

The best plan type depends on your healthcare needs, budget, and preferences regarding provider choice and convenience.

If your claim is denied, you have the right to appeal the decision. Follow these steps:

1. Review the denial reason on your Explanation of Benefits (EOB) or denial letter

2. Gather supporting documentation such as medical records, doctor's statements, or additional information that supports the medical necessity of the service

3. Submit your appeal within the timeframe specified in your denial notice (typically 180 days from receipt of the denial)
- Online through your member portal
- By mail using the appeals form available on our website
- By phone by calling member services

4. Await a decision - we are required to respond to appeals within 30 days for pre-service claims and 60 days for post-service claims

5. If the appeal is denied, you may request an external review by an independent third party

Our appeals department is available to assist you throughout this process.

Our plans include comprehensive mental health coverage in compliance with mental health parity laws. Covered services typically include:

- Outpatient therapy and counseling
- Inpatient mental health care
- Substance use disorder treatment
- Psychiatric medication management
- Emergency mental health services
- Telehealth/virtual mental health visits

Mental health services are subject to the same cost-sharing structure as other medical services under your plan. This means the same deductibles, copays, and coinsurance apply to both mental health and physical health services.

We offer a variety of resources to help you find mental health providers, including our online provider directory that allows filtering specifically for mental health professionals. Additionally, we provide 24/7 crisis support through our dedicated mental health helpline listed on your insurance card.

Yes, our plans cover telehealth services, which allow you to consult with healthcare providers via video, phone, or secure messaging. Benefits include:

- 24/7 access to general medical care for non-emergency conditions
- Specialty telehealth consultations
- Mental health virtual visits
- Prescription services when clinically appropriate

Telehealth visits are typically subject to the same cost-sharing as in-person visits, though some plans offer reduced copays or free telehealth services with our preferred telehealth providers. You can access telehealth services through our dedicated app or web portal, or through in-network providers who offer virtual appointments.

To use our telehealth services, simply log in to your member portal or our mobile app and select 'Virtual Care' to connect with a provider.

A Health Savings Account (HSA) is a tax-advantaged savings account that you can use to pay for qualified medical expenses. Benefits include:

- Tax-deductible contributions
- Tax-free growth on funds
- Tax-free withdrawals for qualified medical expenses
- Funds roll over year to year (no 'use it or lose it' rule)
- Account is portable if you change jobs or insurance

To be eligible for an HSA, you must:
- Be enrolled in a qualified High Deductible Health Plan (HDHP)
- Not be covered by other health insurance (with some exceptions)
- Not be enrolled in Medicare
- Not be claimed as a dependent on someone else's tax return

For 2025, the contribution limits are $4,150 for individual coverage and $8,300 for family coverage, with an additional $1,000 catch-up contribution allowed for those 55 and older.

If you need emergency care while traveling within the United States or internationally:

1. Seek care immediately - All plans cover emergency services regardless of network status

2. Show your insurance card when receiving treatment

3. Notify us of emergency treatment, preferably within 48 hours or as soon as reasonably possible (some plans require notification for hospital admissions)

4. For international emergencies:
- You may need to pay upfront and submit for reimbursement
- Keep all itemized receipts and medical records
- Contact our international assistance line (on your insurance card) for help

While emergency care is always covered, post-stabilization care might require in-network providers to maintain coverage. Our travel assistance program can help arrange appropriate transportation or transfer to in-network facilities if necessary.

Dental and vision coverage depends on your specific plan:

Dental Coverage:
- Some of our health plans include basic dental preventive services
- Comprehensive dental coverage is typically available through separate dental plans
- Our dental plans generally cover preventive care at 100%, basic services at 80%, and major services at 50% after deductible

Vision Coverage:
- Basic vision screenings may be included in your health plan's preventive benefits
- Comprehensive vision coverage for exams, frames, lenses, and contacts is available through separate vision plans
- Our vision plans typically include an annual eye exam and allowance for glasses or contacts

To verify if your current plan includes dental or vision benefits, check your plan documents or log in to your member portal. If you're interested in adding dental or vision coverage, you can explore available options through our website or by calling member services.

Our health insurance plans offer various wellness programs to help you maintain and improve your health:

Physical Wellness:
- Gym membership discounts or reimbursements
- Fitness tracking programs with rewards
- Virtual fitness classes

Health Management:
- Chronic condition management programs
- Health risk assessments
- Personalized health coaching
- Maternity support programs

Preventive Care:
- Annual wellness rewards
- Preventive screening incentives
- Immunization programs

Mental Wellbeing:
- Stress management resources
- Meditation and mindfulness apps
- Employee assistance programs

Financial Incentives:
- Premium discounts for participation
- Health savings account contributions
- Gift cards and merchandise rewards

To access these programs, log in to your member portal and navigate to the 'Wellness' section. Many programs offer financial incentives, so taking advantage of them can help improve your health while reducing your healthcare costs.

You can estimate your potential out-of-pocket costs before receiving healthcare services through several tools:

1. Cost Estimator Tool: Available on your member portal and mobile app, this tool allows you to:
- Search for specific procedures or services
- Compare costs across different providers
- Factor in your specific plan benefits and deductible status
- Get personalized estimates based on your actual coverage

2. Pre-service cost estimates: You can request a written estimate from your provider and then verify coverage with us before receiving care

3. Member Services: Our representatives can help estimate costs for planned procedures

4. Provider billing offices: Many providers can give you cost estimates based on their contracted rates with your insurance

Using these resources helps you budget for healthcare expenses and make informed decisions about your care. Remember that these are estimates, and actual costs may vary based on the specific services provided during your visit.