| Frequently Asked Questions |
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| Contacting OEBB and the carriers |
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What are the phone numbers for OEBB and the insurance carriers?
| OEBB |
(888) 4My-OEBB |
| BenefitHelp Solutions |
(800) 556-2230 |
| ODS Medical/Vision |
(866) 923-0409 |
| ODS Dental |
(866) 923-0410 |
| ODS Pharmacy |
(866) 923-0411 |
| Kaiser Permanente |
(866) 223-2375 |
| Providence Health Plans |
(800) 878-4445 |
| Willamette Dental Group |
(800) 461-8994 |
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| OEBB General Questions |
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Why can’t OEBB subsidize the rate the way OSBA and OEA ChoiceTrust did?
OEBB has no reserve of funds to subsidize rates. The statute that governs OEBB permits an administrative fee to be paid to cover operations costs. Those administrative fees covered operating costs in the first year of OEBB and allowed the Board to pay off the General Funds loan of $4.99 million. The OEA and OSBA Trusts build up trust funds that could be used to subsidize premiums over a number of years.
The Board did; however, reduce the OEBB administrative fee from 1.6 percent to 0.95 percent to help reduce the costs of the overall increases.This represents a 41 percent reduction in the administrative fee from 2008-09 to 2009-10
Wasn’t the size of the OEBB pool and its purchasing power supposed to minimize rate increases more than this?
Over time the premium rate fluctuations are moderated by large buying pools.
This means over a multiyear period you would expect less dramatic rate swings than are seen with smaller groups. A pool can insulate you from rate fluctuations, but not inoculate you from them.
Can OEBB regionally rate premiums?
No. According to Oregon statute 243.864 Sect. 17 (2) the board shall offer a range of benefit designs sufficient to ensure that when benefit plans are first provided by the board to a district, the district and district employees can choose benefit plans that are comparable in design to, and are not more expensive than the comparable costs of, the benefit plans the district provided immediately before the purchase of the benefit plans provided by the board. The board shall determine premiums for each benefit plan based on the benefit plan designs and the aggregated experience of all districts participating in the benefit plans.
Why is the rate increase for Providence so much higher than those of ODS and Kaiser?
All carriers’ rates reflect actual claims experience of the members covered. The reasons given for the rate increase in the Providence plans were higher utilization of certain services by enrollees and higher than expected enrollment in rural areas. Providence identified areas where more diligent management of services will help control utilization and is committed to working with OEBB to control health care costs. These areas include better management of alternative medicine, a new three tiered rate structure for pharmacy and better management of medical imaging.
Why did the rates on my plan increase more than the lower benefit level plan(s)?
Rates increases varied among plans. They were related to the claims experience in the plans. Most rate variations within a carrier’s plan offerings were small.
Why do I have to pay for orthodontia coverage just because I want to use Willamette Dental for my dental plan?
Willamette Dental wanted plans that were in line with plans they normally offer other groups. Usually, Willamette Dental offers dental plans with orthodontic benefits included in the plan. The Board approved the change to allow all Willamette Dental to include orthodontia benefits in the dental plans they offer through OEBB. Now, any OEBB member who elects a Willamette Dental plan will also have orthodontia coverage. Willamette also asked to limit the orthodontia benefit available under OEBB Dental Plans 7 and 8 to the copayment plan. This too is more in line with the benefits typically available through a Willamette Dental plan. These changes allowed OEBB to offer the Willamette Dental plans with minimal increases for employees who didn’t previously have orthodontic benefits on their Willamette Dental plan and a rate reduction for those employees continuing their Willamette Dental coverage that included an orthodontia benefit.
Basic Life
Basic Life - This insurance is for entities who cover or require all employees in a specific employee group (i.e., classified, licensed, or administrative, etc.) to be covered for a specific amount of life insurance. If an entity elects Basic Life coverage for an employee group, this coverage is a mandatory benefit for every employee in that group whether the entity pays the full premium, or the employee is responsible for all or a portion of the premium. OEBB will offer 16 Basic Life plans, but will only allow one of those 16 options per employee group. Basic Life benefits are guaranteed issue for all amounts and can only be selected or changed during the annual plan selection period.
Basic Life insurance is an insurance policy which provides that, in exchange for premiums, the company will pay a benefit when the insured person dies. Benefits will be paid to the beneficiary named by the policyholder.
Optional Life
Optional Employee Life – This plan is optional insurance for employees and is not mandatory. This benefit can be used in addition to Basic Life or offered without the Basic Life benefit. There is one plan offered with values ranging from $10,000 to $500,000 in $10,000 increments. Optional Life benefits for employees are guaranteed issue for amounts up to and including $200,000 if the employee enrolls when initially eligible for OEBB coverage, i.e., during the initial enrollment period (effective October 1, 2009), or within 31 days of his or her date of hire. Amounts above the guaranteed issuance, or coverage requested during future enrollment periods, will require approval by Standard.
Optional Life insurance is term life insurance that is available in addition to any Basic Life coverage plan. This additional coverage allows employees to tailor coverage amounts to meet his or her unique protection needs. This benefit, like Basic Life, will be paid to the beneficiary(ies) on record, or according to law, upon the policyholder’s death.
Optional Spouse/Partner Life – This plan is optional insurance for the employee’s spouse/partner and is not mandatory. The employee must be enrolled in Optional Life to cover an eligible spouse or partner. There is only one plan offered with values ranging from $10,000 to $500,000 in $10,000 increments. Optional Life benefits for spouse/partner are guaranteed issue for amounts up to and including $30,000 if the employee enrolls the eligible spouse or partner when initially eligible for OEBB coverage, i.e., during the initial enrollment period (effective October 1, 2009), or within 31 days of marriage or establishing an eligible domestic partnership. Amounts above the guaranteed issuance, or coverage requested during future enrollment periods, will require approval by Standard. An employee cannot select a value for their spouse/partner which exceeds the value they have selected for themselves.
Optional Child Life – This plan is optional insurance for the employee’s child or children and is not mandatory. The employee must be enrolled in Optional Life to cover an eligible child or eligible children. There is one plan offered with values ranging from $2,000 to $10,000 in $2,000 increments. Optional Child Life benefits are available on a guaranteed issue basis for all amounts if the employee enrolls in the plan when initially eligible for OEBB coverage e.g., during the initial enrollment period (effective October , 2009), or within 31 days of gaining his or her first eligible dependent child.
Basic Accidental Death & Dismemberment
Accidental Death and Dismemberment (AD&D) - If an entity elects Basic AD&D coverage, this coverage is a mandatory benefit. OEBB will offer 16 AD&D plans. An educational entity may choose one plan per employee/member type group. If an educational entity chooses this plan for an employee/member type group each person will automatically be enrolled in this plan. This can be an employer-paid AD&D coverage, or employee AD&D coverage that is required for all employees who participate in your benefits program. Basic AD&D benefits are guaranteed issue for all amounts and can only be selected or changed during the annual plan selection period.
Optional Accidental Death & Dismemberment
Optional Employee AD&D – This plan is optional insurance for employees and is not mandatory. This benefit can be used in addition to Basic AD&D or offered without the Basic AD&D benefit.
There is one plan offered with values ranging from $10,000 to $500,000 in $10,000 increments.
Optional AD&D benefits for employees are guaranteed issue for all amounts. Enrollment or changes in amounts are limited to the first 31 days following the date of hire and open enrollment periods.
Optional Spouse/Partner AD&D – This plan is optional insurance for the employee’s spouse/partner and is not mandatory. The employee must be enrolled in Optional Employee AD&D to cover an eligible spouse or partner in the Optional Spouse/Partner AD&D coverage.
There is one plan offered with values ranging from $10,000 to $500,000 in $10,000 increments.
Optional AD&D benefits for spouse/partner are guaranteed issue for all amounts. An employee cannot enroll their spouse/partner for an amount that exceeds the value they have for themselves. Enrollment or changes in amounts are limited to the first 31 days following the date of hire and open enrollment periods.
Optional Child AD&D – This plan is optional insurance for the employee’s child or children and is not mandatory. The employee must be enrolled in Optional Employee AD&D to cover an eligible child or children in the Optional Child AD&D coverage. There is one plan offered with values ranging from $2,000 to $10,000 in $2,000 increments. Optional Child AD&D benefits are guaranteed issue for all amounts. Enrollment or changes in amounts are limited to the first 31 days following the date of hire and open enrollment periods. Accidental death and dismemberment (AD&D) provides you coverage in the case of accidental death or permanent disability. AD&D insurance is often considered a supplemental plan to life insurance policies.
Short-term Disability
Mandatory Short-term disability – This insurance is for entities that cover or require all employees to have short-term disability coverage. OEBB will offer 18 mandatory Short-term Disability plans. An educational entity may choose one plan per employee/member type group.
If an educational entity chooses this plan for an employee/member type group each person will automatically be enrolled in this plan and the educational entity will be invoiced for each enrollment. Short-term disability benefits are guaranteed issue, but subject to actively at work provisions. Mandatory STD can only be selected or changed during the annual plan selection period.
Voluntary Short-term Disability) – This insurance is for entities that want to offer their employees this benefit as an option, but do not require enrollment. OEBB will offer 18 voluntary Short-term Disability plans. An educational entity may choose one plan per employee/member type group. STD benefits are guaranteed issue if the employee enrolls when initially eligible for OEBB coverage (i.e., during the initial enrollment period effective October 1, 2009), or within 31 days of his or her date of hire.
Coverage requested during future enrollment periods, will require approval by Standard.
STD benefits are subject to actively at work provisions. Short-term disability is a benefit that pays you weekly in the event that you are unable to work because of a covered illness or injury. This benefit replaces a portion of your income.
Long-term Disability
Mandatory Long-term Disability – This insurance is for entities that cover or require all employees to have long-term disability coverage. OEBB will offer six mandatory Long-term Disability plans. An educational entity may choose one plan per employee/member type group. If an educational entity chooses this plan for an employee/member type group each person will automatically be enrolled in this plan.
LTD benefits are guaranteed issue, but subject to actively at work provisions. Mandatory LTD can only be selected or changed during the annual plan selection period.
Voluntary Long-term Disability – This insurance is for entities who want to offer their employees this benefit as an option, but do not pay for the benefit or require enrollment.
OEBB will offer six voluntary Long-term Disability plans. This coverage is not available in addition to a mandatory Long-term Disability Plan. It is a stand alone option.
An educational entity may choose one plan per employee/member type group.
LTD benefits are guaranteed issue if the employee enrolls when initially eligible for OEBB coverage (i.e., during the initial enrollment period effective October 1, 2009), or within 31 days of his or her date of hire. Coverage requested during future enrollment periods, will require approval by Standard. LTD benefits are subject to actively at work provisions. LTD can only be selected or changed during the annual plan selection period.
Long-term disability is a benefit that pays you monthly in the event that you cannot work because of a covered illness or injury. This benefit replaces a portion of your income.
What does OEBB consider optional benefits?
OEBB considers basic life, optional life, accidental death and dismemberment (AD&D), and short- and long-term disability to be optional benefits. These are the new benefits that OEBB will begin offering on October 1, 2009.
What does OEBB consider supplemental benefits?
Supplemental benefits are individual insurance policies paid for by the employee.
Why are optional benefits being offered now?
The Board decided to offer optional benefits so educational entities and members can save money. Current estimates indicate that by offering optional benefits to entities, OEBB will help entities and their employees save an additional $6.3 million annually on top of the nearly $38 million annual administrative savings that entities are realizing now by purchasing medical, dental and vision plans through OEBB.
Which carrier did OEBB select to offer optional benefits?
The Board selected The Standard Insurance Company, or Standard, to offer the optional benefits.
When will people be able to enroll in optional benefits?
OEBB members in educational entities that decide to offer optional benefits will be able to enroll in those benefits during the open enrollment period that begins August 15, 2009.
Are educational entities required to offer optional benefits?
Educational entities are not required to offer employees optional benefits. However, if the entity decides to offer optional benefits to employees, the benefits must be purchased through OEBB. In addition, an entity is not required to offer optional benefits to each employee group within the entity, but may do so. As with all of the OEBB benefits, each employee group is able to select the coverage it wants to offer to its employees even if the plans are not the same as those in another employee group at the same entity.
Can an educational entity or employee group decide to choose some of the optional benefits, but not all?
Each entity or employee group has the option of choosing whether they want to make a benefit available to an employee group and at what benefit level. Each entity or employee group may select or allow the following coverages for each employee group:
- Life – Can offer a basic life benefit amount that is mandatory for every employee, multiple choices available with flat amounts and multiples of salary.
- Accidental Death and Dismemberment (AD&D) – Can offer a basic AD&D benefit amount that is mandatory for every employee, multiple choices available with flat amounts and multiples of salary.
- AD&D – Can offer optional AD&D for employees to voluntarily enroll in an amount (available in $10,000 increments from $10,000 up to $500,000); can offer optional spouse and/or child(ren) AD&D if offering basic or optional employee AD&D.
- Short-term Disability – Can offer one mandatory short-term disability benefit or one voluntary short-term disability option for employees to choose to enroll in.
- Long-term Disability – Can offer one mandatory long-term disability benefit or one voluntary long-term disability option for employees to choose to enroll in.
Can districts continue to offer supplemental plans even though OEBB offers optional benefits?
An entity may continue to offer supplemental benefits plans until OEBB offers the benefit. Entities may also allow for payroll deductions for any non-group plan (i.e., individual policy).
What is the definition of PPO?
PPO means Preferred Provider Organization
What is the definition of POS?
POS means Point of Service
What is the definition of HMO?
HMO means Health Maintenance Organization
What is the definition PCP?
PCP means Primary Care Physician
What is a deductible?
A deductible is a specific flat-dollar amount an individual must pay out of their own pocket toward covered expenses before a plan begins to pay toward expenses. Deductibles carry through a twelve-month period – October 1 through September 30. Plan deductibles are listed on the summary of benefits or in your employee benefit booklet. To obtain the Summary of Benefits go to http://www.oregon.gov/DAS/OEBB/summaryofbenefits.shtml.
Some plans have a family maximum annual deductible. Basically, this means that once a certain number of your family members meet the annual deductible, services for all family members will be paid at the plan benefit level. For example, if a plan has a $100 individual deductible, and a family deductible of $300 (shown as $100/$300 in the summary of benefits), once an individual has paid $100 for covered services, benefits would kick in at the benefit level for the type of service received for the remainder of the twelve-month benefit year. If two more family members meet their $100 deductible, for a combined family deductible amount of $300, no additional family members will need to meet their deductibles.
Will I be credited for any deductible and/or out of pocket maximums from prior carriers?
The OEBB plan year begins October 1 and runs through September 30, and, therefore, deductibles and out-of-pocket maximums start over. The OEBB Board made this decision on June 9, 2008.
What is a benefit year? What is a plan year?
A benefit year refers to the twelve-month period which deductibles, out-of-pocket maximums, or any annual benefit maximums accrue or apply. A plan year refers to the twelve-month period designated for the purpose of providing annual open enrollment periods, benefit changes, rate changes and/or contractual changes between an insurance carrier and the benefit plan sponsor such as OEBB.
OEBB’s benefit year and plan year are the same -- October 1 through September 30.
What are copayments?
Copayments are pre-determined, flat-dollar fees for certain services (e.g., office visits) paid at the time of service. Typically, you don’t have to meet the plan deductible before receiving the benefit of a copayment. Copayments usually don’t apply toward the maximum out-of-pocket and will be required even after the out-of-pocket maximum is reached.
What does the term coinsurance mean?
Coinsurance means members split their eligible healthcare costs with the insurance carrier. For example, if your health plan has an 80/20 in-network (out-of-network coinsurance levels will differ from the in-network coinsurance levels) coinsurance rate for specific services (e.g., OEBB medical plans 3 through 9), this means after the deductible has been satisfied, the insurance company is then responsible for 80 percent of the eligible charges and the member is responsible for the balance. Once a member reaches their plan year out-of-pocket maximum, the insurance carrier will pay for 100 percent of the eligible expenses (subject to plan limitations).
What is an out-of-pocket maximum?
An out-of-pocket maximum also is referred to as the “stop loss” amount. Once you have paid that amount out of your pocket for covered services, you no longer pay for most covered services. Out of pocket maximums are calculated on an individual basis.
- Here is an example of how this works on a plan with a deductible, coinsurance and a copayment:
Using OEBB Medical Plan 3: a) you pay the first $100 in covered services; b) you pay 10 percent of the next $5,000 in covered services (or $500); and c) the plan pays 100 percent of all costs for covered services through the remainder of the benefit year (October 1 through September 30). In this example, you would continue to pay $10 for each in-network office visit. Under OEBB Medical Plan 3, the office visit copayments do not apply toward the deductible or the maximum out-of-pocket.
- Here is an example of how this works on a plan with no deductible and no coinsurance, just copayments:
Under OEBB Medical Plan 2 (either the Kaiser Permanente or the Providence Health Plan option), your copayments apply toward the maximum out-of-pocket. If you use in network providers, you would pay your copayment ($5 for office visits or $100 for each emergency room visit) until you’ve paid out $600 in the benefit year (October 1 through September 30). If you meet that $600 maximum, then all covered services received using an in-network provider would be covered in full through the remainder of the benefit year (October 1 through September 30).
Will my copayments go toward my deductible and out-of-pocket?
Copayments on OEBB Medical Plans 1 and 2 (either Kaiser Permanente or Providence Health Plan) will count toward the maximum out-of-pocket. Copayments made for OEBB Medical Plans 3 through 9 (offered through ODS Health Plan) will not count toward the deductible or the out-of-pocket maximum.
How much will be covered for naturopathic, chiropractic and acupuncture?
Each medical plan features a total combined benefit maximum of $2,500 per plan year for all three services.
Do I need a referral to see a medical specialist?
For Kaiser Permanente, members may self-refer for outpatient drug and alcohol treatment, outpatient mental health, cancer counseling, optometry, obstetrics/gynecology, occupational health, and social work. Generally, for other specialty services, a referral is needed to see a specialist for the first time.
For Providence and ODS, you are free to see a specialist without a referral; however, the specialist may require a referral.
Is weight-loss/bariatric surgery covered?
At this time, coverage for services, supplies, and surgery for weight loss and obesity are not covered.
Will OEBB’s plans cover pre-existing conditions?
There will be no new pre-existing condition limitations under OEBB plans; however, a waiting period will apply for Dental and Vision services that are not considered preventive if the following applies:
Coverage for previously OEBB-eligible employees or dependents who did not initially enroll in the dental and/or vision plans now wants to enroll in the dental and/or vision options during a future open enrollment period will be limited to routine and preventive care for the first 12 months and subject to a 12-month waiting period for orthodontia coverage. Eligible employees who enroll in the dental or vision plans, or add previously OEBB- eligible dependents to the dental and vision plans due to a loss of other coverage will not be subject to waiting periods. If an OEBB-eligible employee has OEBB sponsored dental or vision coverage, they will not be subject to the waiting periods.
What is my cap and what will my insurances cost me?
Each educational entity offers varying contributions to employee’s health benefits, so you will need to contact your educational entity to find out the contribution offered to your employee group and the costs you are required to pay for coverage.
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| Kaiser Permanente |
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Do I have to choose Kaiser Permanente dental coverage or vision coverage if I choose Kaiser Permanente medical coverage?
No. You may choose any dental or vision plan when you choose Kaiser medical.
Do I have to choose Kaiser Permanente medical coverage if I choose Kaiser Permanente dental coverage?
Yes. You must have Kaiser medical coverage through OEBB or another employer to choose the Kaiser dental plans for yourself or any eligible dependents.
Do I have to choose Kaiser Permanente medical coverage if I choose Kaiser Permanente vision coverage?
Yes. You must have Kaiser medical coverage through OEBB to choose the Kaiser vision for yourself or any eligible dependents. If one member opts out and is covered under their spouses Kaiser medical plan, this does not qualify. You must have your own OEBB Kaiser medical coverage to be able to choose Kaiser vision.
Why do you need to have Kaiser Permanente medical coverage to choose Kaiser dental or vision plans?
This was the agreement made between Kaiser Permanente and OEBB.
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| ODS Medical |
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Do all expenses apply to a member’s medical maximum out of pocket?
No. Expenses applied toward the annual deductible do not apply toward the out-of-pocket maximum (except for Plan 9). Fixed dollar copayments and disallowed charges do not apply toward the annual deductible or out-of-pocket maximum.
In addition (and to provide more clarification), a member is responsible for paying the following costs (they do not accrue toward the member’s out-of-pocket maximum and the member must pay for them even after their out-of-pocket maximum is met):
• Fixed dollar copayments;
• The out-of-pocket expenses for transplants performed at out of network transplant facilities;
• The service authorization cost containment penalty; and
• Disallowed charges.
If a member is on a plan that has medical copayments, does the deductible need to be met before I have to begin paying copayments?
Services with copayments always require a copayment and one does not need to meet the deductible to receive the benefit associated with the service (exception to this rule is with the emergency room copayment. Members are responsible for the emergency room copayment and the deductible must be met before any carrier payment is made).
What are my benefits while traveling?
If a member is traveling out of the service area and seeks care from an out-of-network physician/provider, the benefit will be paid at the out-of-network benefit level. The Plan will process charges for those services as follows: maximum amount is the lesser of the amount payable under any supplemental provider fee arrangements and the seventy-fifth (75th) percentile of fees commonly charged for a given procedure in a given area, based on a national database.
What if I am out of the service area and have a medical emergency?
If a member is out of the service area and has a medical emergency, the member should go to the nearest emergency room. Benefits will be paid at the in-network benefit level, subject to maximum plan allowable, for medical emergencies.
(To view additional FAQ’s, please visit the ODS Web site at http://www.oregon.gov/DAS/OEBB/docs/Carriers/ODS/ODSfaq.pdf)
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| Providence Medical |
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Is Providence Health Plan an HMO?
No, Providence is an Exclusive Provider Organization (EPO) in Oregon. An EPO typically works like a Preferred Provider Organization (PPO) plan or a Point of Service (POS) plan.
Do I need a referral to see a specialist?
Providence does not require that you select a PCP, but we encourage you to establish a relationship with a personal physician (family practice, internist, or pediatrician). These providers can manage your overall health care and are the best place to initiate care. However, you are free to see a specialist without a referral.
Does Providence Health Plan have a statewide network?
Yes, Providence has a statewide network and it is expanding daily. In addition, Providence contracts with most of the hospitals in Oregon. For an online provider/facility directory visit: https://www.providence.org/PHP_ProviderDirectory/Pages/PHP/EnterSelections.aspx
Does Providence Health Plan have providers outside of Oregon?
Yes, Providence has a national provider network in all states. This means early retirees or dependents living out-of-area have access to thousands of providers and benefits are paid in-plan when you seek care from one of our national network providers.
Does Providence Health Plan contract with Legacy Health System and OHSU in Portland?
Providence does not contract with Legacy Hospitals with the exception of some specialized services at Legacy Emanuel. The same applies to Oregon Health Sciences University. These are the Metro area trauma facilities. Trauma services are considered in-plan services as well as some other specialty services that can’t be provided elsewhere. If your provider feels you require other services at these facilities that can’t be provided elsewhere, they can submit for prior authorization to have services paid in-plan. You may seek elective services at any non-contracted hospital by using your out-of-network benefit, subject to deductible and coinsurance.
Am I able to get my prescriptions from any pharmacy (Providence)?
Providence does require you to use a contracted pharmacy but we contract with virtually every retail chain and many independent pharmacies. Check the online directory for a pharmacy near you at https://www.providence.org/PHP_ProviderDirectory/Pages/PHP/EnterSelections.aspx. You may access any of the national contracted chain pharmacies anywhere in the United States. If you need to fill a prescription while in Texas for example, simply look for a chain pharmacy such as Walgreens or Rite Aid and present your member ID card.
Does Providence have mail-order pharmacy services?
Yes, Providence contracts with three vendors for mail order that you may select. These are WellPartner (Portland based), Walgreens, and Postal Prescription Services (PPS). Providence’ OEBB Pharmacy 1 plan offers a 90-day supply of maintenance drugs for two copays. Providence also offers members the additional benefit of accessing that mail-order benefit on a walk-in retail basis at three preferred retail vendors that have agreed to match our mail order rates. These are Walgreens, Fred Meyer, and Costco.
(To view additional FAQ’s, please visit the Providence website at http://www.oregon.gov/DAS/OEBB/docs/Carriers/Providence/Providencefaq.pdf)
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| Dental |
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Will dental coverage begin again at 70 percent or will employees be given credit for the incentive level they have earned? What if the employee was not in an incentive-level plan prior to joining OEBB?
The level of coverage a member receives will be credited by OEBB based on the employee’s date of hire. For example, employees with three or more years of service that choose to enroll in one of the incentive dental plans (OEBB Dental Plans 1 through 3) will come into the program at the 100 percent benefit level. To maintain that level, the member must receive routine cleaning and maintenance care each year thereafter. Otherwise, the coverage will decrease by 10 percent the following year. (Note: This is only for new educational entities coming into OEBB for the first time.)
What happens if I did not enroll in a dental plan this year and I want to enroll next year?
Members who do not enroll in the dental and vision plans when originally eligible and elect to enroll during a future Open Enrollment will be eligible for routine services only for the first 12 months of coverage. Dental coverage will allow only preventive services and no orthodontia. Vision coverage will allow only eye exams.
What if I didn’t enroll in dental coverage during Open Enrollment because I had other coverage, then I lose my other coverage?
The 12-month waiting period for routine services does not apply due to loss of other group coverage.
ODS Dental
How often are cleanings allowed?
Prophylaxis (cleaning) or periodontal maintenance is covered once in any six-month period.
How will incentive dental information transfer?
ODS will use the employee’s date of hire (DOH) to determine incentive level and effective incentive levels will be increased by 10 percent (unless of course the member is already at 100 percent). The above information is regardless of what type of dental plan the member may be transferring from constant or incentive.
Effective 10/1/2009, if a current OEBB member moves from a constant plan (plans 4, 5, or 6) to an incentive plan (plans 1, 2, or 3) will their incentive level start at 70 percent, regardless of their original date of hire?
Yes.
If I have dual dental coverage, does the maximum benefit double as well? For example, on dental plan 2, if two members (husband and wife) have dental plan 2, would their total maximum be $3,000 per member per plan year in lieu of the $1,500 per member per plan year?
If a member has dual coverage with a plan maximum (e.g., dental plan with $1500 plan year maximum), the primary plan will pay first. The secondary plan will pick up balances on allowable expenses. Once the member has met his or her maximum on the primary plan ($1500 has been paid out), then the secondary plan will pay, as if they are primary, until it too has met the $1500 maximum (dollars paid as secondary, prior to the primary maximum being met, also apply toward the secondary $1,500 maximum).
If I have dual dental coverage through ODS, and my dentist charges more than your usual and customary allowable, will the other policy pick up the remainder of the charges through coordination of benefits?
ODS as the secondary plan will pay up to the highest allowable not to exceed the billed amount. If husband and wife both have ODS, the allowed amount will be the same for both plans. If there is a charge more than the allowed amount, the member would still be responsible for the extra charge. When a member visits a dentist that is in the ODS premier network, the member will not be billed for charges over the contracted fees, because as a participating provider, the provider will write off the amount that is billed over their contract allowance.
(To view additional FAQs, please visit the ODS Web site at http://www.oregon.gov/DAS/OEBB/docs/Carriers/ODS/ODSfaq.pdf)
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| Pharmacy |
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Which mail-order pharmacies am I able to use?
- Kaiser – Kaiser Pharmacy (contact the pharmacy at the facility that you use)
- ODS – Wellpartner
- Providence – PPS (Postal Prescription Services), Walgreens, Wellpartner
In addition, you have access to 90-day supplies of maintenance medications at preferred retail stores such as Costco, Fred Meyer and Walgreens pharmacies.
What are specialty medications?
Specialty medications are often indicated to treat complex chronic health conditions. Respecting that specialty treatments often require special handling techniques, careful administration, and a unique ordering process, enhanced member services are provided by each individual insurance carrier.
How do I know if my medication requires a prior authorization (PA)?
All specialty medications require a prior authorization by the insurance carrier before the medications can be dispensed. Prior authorization (PA) refers to the process by which an enrollee obtains approval from the insurance carrier prior to purchasing a specific drug. Failure to obtain required service authorization will result in denial of benefits. Certain prescription drugs and/or quantities of prescription drugs may require a prior authorization. Prior authorization programs are not intended to create barriers or limit access to medications. The practice of administering prior authorization provisions is intended to support cost effectiveness, promote proper use of medications and to ensure the safety of the members.
ODS Pharmacy
Will my medication be covered under the ODS Pharmacy benefit plan?
The coverage for medication is based on the OEBB selected plan design and the placement of the medication on the ODS/OPDP select formulary which can be accessed on the OEBB Web site. The formulary is updated periodically and could change at any time.
Are there any medications Wellpartner (mail order) does not dispense?
Wellpartner does not provide “compounded” or “specialty” medications.
If I order prescriptions through the Wellpartner mail-order program, how long will it take for my prescriptions to arrive via mail order?
In most cases, your order will arrive within four to seven business days after your order is received. Please allow more time for new prescriptions.
(To view additional FAQ’s, please visit the ODS website at http://www.oregon.gov/DAS/OEBB/docs/Carriers/ODS/ODSfaq.pdf)
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| Vision |
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What happens if I did not enroll in a vision plan this year and I want to enroll next year?
Members who do not enroll in the dental and vision plans when originally eligible and elect to enroll during Open Enrollment, will be eligible for routine services only for the first 12 months of coverage. Dental coverage will allow only preventive services only and no orthodontia. Vision coverage will only allow eye exams.
What if I didn’t enroll because I had other vision coverage and then I lose my other coverage?
The 12-month waiting period for routine services only does not apply due to loss of other group coverage.
ODS Vision
Are disposable contacts covered?
Disposable contacts are covered up to the plan maximums on plans 1 through 4 and up to the type of service maximum on plan 5.
Vision Plan 1 has a $10 copayment for a routine eye exam. Is the provider reimbursed for the balance by ODS? Does the amount the provider is reimbursed by ODS go to the plan maximum?
Yes. The amount paid by ODS will reduce the amount left available for frames and lenses. This means that the cost of the exam goes towards the $250 plan year maximum, so if the exam cost is $100, the remainder left to spend is $160. $250-$90 (cost of exam, less the copayment) equals $160.
Do I have to see a certain eye doctor?
There is a difference on what the plan will pay depending on if the vision provider is participating or non-participating with ODS. The payments on specific claims will be based on the individual agreement between ODS and the eye doctor. If you see a participating provider your responsibility may be lower, as some disallowed charges are provider write off, not patient responsibility. Wal-Mart Vision Centers, Binyons and Lens Crafters are all part of the network. Costco also is part of the network, however, you will pay the bill up front and then submit for reimbursement from ODS.
(To view additional FAQ’s, please visit the ODS website at http://www.oregon.gov/DAS/OEBB/docs/Carriers/ODS/ODSfaq.pdf)
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| COBRA (Consolidated Omnibus Budget Reconciliation Act) |
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Where do I send my COBRA payment?
OEBB has contracted with BenefitHelp Solutions to administer COBRA; payments will be made through BHS. Please make payments payable to BenefitHelp Solutions and payments can be mailed to, P.O. Box 67240, Portland, OR 97268-1240.
You may contact BHS directly at (800) 556-2230 or via the Web at www.benefithelpsolutions.com
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| Dependent Eligibility |
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What is the eligibility age of dependent?
Biological, step and adopted children under age 19 are eligible for coverage under OEBB benefit plans. Eligible employees also may obtain coverage for dependent children that are legal wards of the court or that they, their spouses, or domestic partners are required to support.
Dependent children age 19 to 26 are eligible for coverage if they are:
- Attending school full time, excluding foreign students; or
- Living in the home of the eligible employee more than six months of the calendar year, and the eligible employee provides more than half the yearly support; or
- Incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability.
Dependent children older than age 26 are eligible for benefit coverage if they are incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability and were covered under an educational entity plan prior to reaching the age of 26. There are some exceptions, please see your educational entity with questions.
Dependent children of all ages must be unmarried and not have a domestic partner to participate in OEBB sponsored benefit plans.
A complete version OEBB’s eligibility rules are at http://www.oregon.gov/DAS/OEBB/administrativerules.shtml
When do I need to fill out an Affidavit of Dependency?
An Affidavit of Dependency is required when a child that is non-biological or adopted and is living in the home of the eligible employee, is not more than 18-years-old, no one else can claim them as a dependent. If the child is between the ages of 19 and 26, they must meet the criteria listed above.
Can I add my niece or grandchild to my insurance?
Yes. They must qualify as defined on the Affidavit of Dependency form. http://www.oregon.gov/DAS/OEBB/docs/Forms/AffidavitofDependency3xls.pdf
If they qualify, you may add them within 31 days of the date they come to live with you or during Open Enrollment.
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| Double (Dual) Coverage Examples and Coordination of Benefits |
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When an OEBB member has dual OEBB coverage, does the deductible have to be satisfied or will it be picked up by the other plan?
The deductible still must be satisfied prior to any benefit reimbursement. For example, if a member is dual covered under OEBB medical Plan 3, there is a $100 deductible that must be met. The following is an example of how this would work: ODS receives a claim with eligible charges of $120; $100 is applied to the primary plan's deductible. ODS would reimburse the provider 90 percent (assuming the service was in-network and not a copayment service) of the remaining balance of $20, which equals $18. ODS would then apply the same $100 to the secondary coverage's deductible. ODS would pick up the additional $2 of eligible charges, which was not applied to the deductible, as the secondary carrier. Total member responsibility for this claim - $100.00. Deductible is now satisfied on both plans.
Coordination of benefits (COB) is confusing. Can you provide some examples for dual coverage with medical plans so I can get a better understanding of how benefits will be coordinated?
In most cases, once the deductibles are satisfied, the member will not have any further out of pocket expenses, unless limitations and/or maximums are met. If you seek services from out-of-network providers, you will be responsible for any charges in excess of the ODS maximum plan allowance (MPA). If you have secondary coverage through a non-ODS plan, please check with that plan’s insurance carrier on how they handle coordination of benefits. Please see below for sample scenarios.
Example #1
An ODS member has dual medical coverage. The primary coverage is through ODS. The member is covered under OEBB Plan 3 with a $100 individual deductible/$300 family deductible. The secondary coverage is through the member’s spouse, ABC company, with a $500 individual deductible/$1,000 family deductible. The first $100 in eligible charges would apply to both deductibles. Once the $100 deductible is met on the OEBB/ODS plan, ODS would begin to pay benefits. Eligible charges would continue to apply to the secondary plan’s $500 individual deductible, until it is met. Once the secondary’s plan deductible is met, the primary plan (ODS) would pay its normal benefits and the secondary plan would pay the remainder, leaving a zero dollar balance to the member in most cases.
Example #2
A married couple has dual coverage under the OEBB/ODS plans. The member for the example below has OEBB Plan 7 as primary and OEBB Plan 3 as secondary. The member goes to the doctor for an in-network office visit. If the charge for the visit is $200, Plan 7 applies $200 toward the deductible and pays nothing to the provider. Plan 3, as the secondary plan, pays $190 to the provider (total office visit cost less the $10 copayment). The member now has met $200 of Plan 7 deductible, $0 of Plan 3 deductible and pays the $10 copayment to the provider. The member goes for another in-network office visit. This time the charge is $350. Plan 7 applies $300 toward the deductible, and then pays 80 percent of the remaining $50 ($40). Patient responsibility under Plan 7 would be $310 (remaining deductible + coinsurance of 20 percent). Plan 3, as the secondary plan, would pay $340 if it were the only plan in place (total office visit cost less the $10 copayment), but since the patient responsibility is $310 after plan 7 has been applied, Plan 3 would pay the balance of $310. The member has now met the $500 Plan 7 deductible, but has not yet met any deductible on Plan 3.
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| Medicare |
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Does OEBB offer a supplemental insurance plan?
At this time, OEBB does not offer a supplemental insurance. You may check with PERS (Public Employees Retirement System) at (888) 320-7377 to see what type of plans they offer. You also may check with your current insurance carrier to find out if you can purchase retirement insurance through them. Your educational entity also is a good source of information and may be able to suggest other alternatives.
What if I am still working even though I’m eligible for Medicare?
An employee may work beyond age 65. If so, and if the employer has 20 or more employees and provides an employer group health plan, the worker over age 65 must be covered under the same group plan with the same benefits as those employees under age 65. The employer plan is primary to Medicare, providing full benefits before Medicare benefits are applied.
Should I also get Medicare Part B?
You may want to delay enrollment in Part B as long as you or your spouse are working and are both covered by an employer plan. You will qualify for Medicare supplement open enrollment once you leave the employer plan and start Part B. Consider:
- How fully your employer plan covers doctor and other health services also covered by Part B.
- Whether the secondary benefits Part B would pay are worth the cost of the monthly premium.
Can I delay applying for Medicare Part B?
Yes, but do not do so unless you or your spouse is working and you are covered by an employer plan, or else you face a penalty. To avoid higher premiums for late enrollment in Medicare Part B, notify Social Security that you are still working and covered by your employer plan (not a plan for retirees) and wish to decline enrollment in Part B. Document your conversation by recording the date, name of person you speak with, and notes on what is said.
If I delay enrollment in Part B, what happens when my employer coverage ends?
If you are 65 or over, you have a Special Enrollment Period for people covered under an employer group health plan. This allows you to enroll in Part B during the eight-month period beginning with whichever of these comes first:
- The month you or your spouse end employment.
- The month your group health coverage ends.
Special Enrollment Period rules do not apply to you if you stop working or lose your employer coverage during your Initial Enrollment Period (the time you first are eligible for Medicare).
Contact Social Security to discuss the best time to enroll in Part B.
Can I enroll in Medicare Part B while I'm still working and covered by my employer plan?
Yes, you may contact Social Security and enroll in Medicare Part B at any time while you are working and covered by the employer plan.
If you enroll while you are still working, you may start coverage at the first of the month in which you enroll or at the first of any of the three months after that.
(Note: Contact your benefits administrator at work to find out whether enrolling in Part B at this time is required or to your advantage.)
For more information about Medicare, please visit egov.oregon.gov/DCBS/SHIBA/medicare.shtml.
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| Opt Out and Waive |
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What is the difference between Opt out and Waive?
Opting out only pertains to medical coverage and you must have other group coverage to opt out of the OEBB medical plans. If you choose not to enroll in the dental and/or vision plans, it is considered a waive. You also may choose to waive all OEBB benefits if you do not have other medical coverage. See the OEBB administrative rule below regarding opting out and waiving”
OAR 111-040-0050
“Opting out of coverage” means that an individual elects not to enroll in a medical plan and is eligible to receive a portion of the cash contribution or other type of remuneration as provided for under a collective bargaining agreement, documented district policy, or employment contract.
“Waiving benefits” means that an individual elects not to enroll in any one of the benefit plans available under the OEBB-sponsored benefits program and is not eligible to receive any portion of a cash contribution or other type of remuneration.
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| Out of Area Dependents |
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My child is attending college in another state, what doctors can they go to?
If a student/dependent lives outside of the service area, you will need to notify the insurance carrier and let them know that you have an out-of-area dependent. Services will be charged at the in-network cost if they go to a provider within a 30-mile radius of their residence. Fees charged by out-of-area physicians and providers will be reimbursed at the maximum plan allowable for those services.
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| Provider Searches |
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Is my doctor in network with ODS Health Plans or Providence Health Plans?
Below are the links that will take you to the provider directory or search features on the carriers’ Web sites. If your doctor is a preferred provider with either carrier, you will pay the in network co-insurance or copayment. If your doctor is not a preferred provider with either carrier, you will pay the out-of-network co-insurance or copayment.
ODS Health plans:
Provider Search, click here:
https://www.odshealthplans.com/provSearch/networkProviderSearch.do?hiddenRequestType=networkProviderSearch&networkProviderGroup=ODS&action=Go
Providence Health Plans:
Provider Search, click here: https://www.providence.org/PHP_ProviderDirectory/Pages/PHP/EnterSelections.aspx
Provider Directory, click here:
https://www.providence.org/healthplans/members/directories/default.aspx
Willamette Dental and Kaiser facilities can be found at their respective Web sites including www.willamettedental.com/oebb and http://my.kp.org/nw/oebb/.
What if my doctor is not in the ODS network?
You may nominate your provider by sending an e-mail to medical@odscompanies.com. You will need to include the following in your e-mail: provider’s first and last name, clinic or practice name, practice address, city, state and zip code, and provider telephone number.
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| Qualified Status Changes/Changing Insurance Mid-Year |
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Am I able to change my optional benefit plans at any other time than open enrollment?
All of the OEBB plans are set up in a way to allow for changes that are consistent with Qualified Status Changes. An employee can sign up for optional benefits when they initially are eligible (at the time of hire, or in the case of OEBB’s optional benefits during the initial open enrollment period), or following a Qualified Status Change that would allow for enrollment (or disenrollment). For example, if an employee got married, they could enroll their new spouse in life insurance; if an employee gets divorced, they would need to cancel the group spouse life coverage.
The plans also allow enrollment, disenrollment, increases or decreases of life and/or AD&D amounts, addition of new dependents, or removal of eligible dependents during the annual open enrollment period.
While many restrictions are required to ensure the OEBB plans comply with IRS regulations for pre-tax benefits, these restrictions are also a part of the contractual agreements OEBB has with all carriers. These restrictions help to prevent adverse selection and therefore help to keep the overall costs of the OEBB benefit plans at their lowest.
When can I add my new spouse or new baby to my insurance?
You can add any newly-eligible dependents within 31 days of the event by filling out an enrollment form, with the exception of a birth or adoption. The coverage is effective from the date of birth, adoption decree or placement of adoption. A new dependent may cause a premium increase. http://www.oregon.gov/DAS/OEBB/docs/Forms/Enrollmentform.pdf
When can I make changes to my current enrollments?
You can make changes to your plans each year during Open Enrollment which is from August 15 through September 15.
What if I lose my other group insurance coverage and I have opted out of the OEBB coverage?
Loss of other group coverage is considered a Qualified Status Change (QSC) so you can enroll yourself and your family in the OEBB plans by filling out an enrollment form within 31 days of losing other group coverage.
What if I gain other group coverage through my spouse’s employer, can I drop my OEBB coverage?
This is considered a QSC, so you can opt out of the OEBB coverage by filling out an enrollment form within 31 days of gaining the other “group” coverage. Group coverage is any coverage that is employer sponsored; private or individual insurance is not considered group coverage.
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| Retirees |
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What is the cost of plans and where do I send my payment?
You will need to contact your educational entity payroll office to find out the cost and to set up payment arrangements.
If I didn’t enroll in one of the available plans or didn’t enroll my spouse, can I enroll later?
Let’s use this example: if you only enrolled in medical, you cannot add vision or dental during a future Open Enrollment period. However, if you have a QSC (Qualified Status Change) such as a marriage, you can add your newly-eligible spouse within 31 days, but you can only add your newly-eligible spouse to the plans that you are currently enrolled in. You cannot add medical, dental or vision coverage if you did not enroll during the first Open Enrollment period you were eligible for through OEBB..
As an active employee, I only had dental and vision. At retirement, can I now enroll in medical? Can I now enroll my spouse?
OEBB requires that an individual be covered under an educational entity or OEBB medical plan (as a dependent or the employee) at the time of retirement. Coverage must be continuous. Application for a retiree plan will need to be made within 31 days of retirement, or within 31 days of losing coverage under an active employee medical plan sponsored by an educational entity or OEBB. Please note that a retiree cannot return to the OEBB plans if there is any interruption in coverage under an educational entity or OEBB-sponsored medical plan. OEBB will not recognize any other employer-sponsored medical coverage as continuous coverage.
What happens when a retiree turns 65?
The current rules state that retirees can continue coverage under OEBB medical, vision and dental coverage until the first month in which they reach age 65 and/or become eligible for Medicare, whichever occurs first. (There is an exception to this for individuals who qualify for Medicare due to end stage renal disease). If the educational entity allows, retirees may elect to continue dental coverage only, but they are not eligible to continue medical, pharmacy or vision.
What happens to my spouse and/or children when I turn 65?
If a retiree becomes eligible for Medicare coverage, but his or her currently enrolled eligible dependents are not, these eligible dependents may continue OEBB medical and dental insurance coverage until they no longer meet OEBB eligibility requirements or become eligible for Medicare coverage, whichever occurs first. The eligible individuals must submit an application for enrollment to the educational entity payroll office within 31 days of the retiree’s eligibility for Medicare.
What is an early retiree?
An early retiree is someone who retires before the age of 65.
If I am an OEBB early retiree and I go back to work as an active employee, will the insurance carrier coordinate benefits between the active coverage and the retiree coverage?
The active coverage would be primary and the retiree coverage would be secondary.
Can my spouse remain on my plans if they turn 65 or become Medicare eligible?
Eligible dependents who were covered on a plan at the time of retirement who are eligible for Medicare, or who become eligible for Medicare may continue on OEBB medical plans until the retiree becomes eligible for Medicare with the following exception: Coverage will end for dependents enrolled on a Kaiser medical plan. There will be a coordination of benefits (for the spouse) and Medicare will be primary and OEBB insurance will be secondary. Some educational entities have collective bargaining agreements (union contracts) in place that will not allow coverage for dependents of an early retiree. Please check with your educational entity for specific coverage options allowed by your entity.
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