Health Insurance

HMO vs. PPO-Type Indemnity Plan
HMO ZIP Code Service Areas
Choosing a Health Care Provider
Case Management
Health and Pharmacy Claims
Coordination of Benefits (COB)
More Information About Health Insurance

HMO vs. PPO-Type Indemnity Plan 

An HMO (Health Maintenance Organization) is a type of managed care plan regulated by the Oklahoma State Insurance Department. A member in an HMO must select a Primary Care Physician (PCP) who coordinates all health care needs. To be eligible to enroll in an HMO, an employee must live or work within that HMO’s ZIP Code service area.  (See HMO ZIP Codes in the Employee Benefit Options Guide)

An indemnity plan is a traditional fee-for-service insurance plan that gives the member the freedom to visit any licensed health care professional without a referral. The member is responsible for deductibles, copays, and coinsurance, and a calendar year out-of-pocket limit typically applies. Once the out-of-pocket limit is reached, the plan typically pays 100% of allowed charges for covered services for the rest of that plan year.

All health plans offered through OSEEGIB provide medical and prescription drug benefits. Benefits are subject to each plan’s rules and certain cost-sharing features such as, copays, deductibles, and coinsurance.

For Plan Year 2012, there are 15 health plan options available to employees:

HealthChoice Plans
HealthChoice High
HealthChoice High Alternative
HealthChoice Basic
HealthChoice Basic Alternative
HealthChoice S-Account Plan
HealthChoice USA Plan

HMO Plans
CommunityCare Standard
CommunityCare Alternative
CommunityCare Wellness Alternative Plus
GlobalHealth Standard
GlobalHealth Alternative
GlobalHealth Wellness Alternative Plus
UnitedHealthcare Standard
UnitedHealthcare Alternative
UnitedHealthcare Wellness Alternative Plus

HMO ZIP Code Service Areas 

The ZIP Code list designates the service areas for CommunityCare, GlobalHealth, and UnitedHealthcare HMOs.

For more detailed information about a specific HMO, such as participating providers or a list of formulary drugs, please contact the HMO directly.

Choosing a Health Provider 

When enrolling in an HMO, an employee must designate a Primary Care Physician (PCP). If they do not select a PCP, one is assigned for them. The first point-of-contact when seeking health care is the PCP. The PCP is responsible for coordinating all health care, including authorizing visits to specialists and hospitalizations. Failure to obtain authorization from the PCP can result in the denial of claims.

When enrolling in one of the HealthChoice plans, an employee should confirm their provider or facility participates in the HealthChoice Provider Network. The most up-to-date list of Network Providers is available on the HealthChoice website or by contacting HealthChoice Member Services.  (See Contact Information for Health Insurance) If the employee decides to use a non-Network provider or facility, the employee’s out-of-pocket costs can be substantially higher.

Each plan issues identification cards to its members. Providers and facilities often require a copy of the employee’s plan ID card and drivers license or photo ID when they receive health care.

Case Management 

Case management refers to the coordination of benefits and services on behalf of members and dependents. All health plans available through OSEEGIB have case management services available to their members and can provide personalized assistance, and coordination of medical services, and also help maximize benefits through early intervention and on-site visits when appropriate.

Case management is helpful in the following situations:

• Cancer
• Rehabilitation
• HIV/AIDS
• Terminal illness
• Stroke
• Pregnancy and pre-term infants
• Transplants
• Mental health and substance use disorder
• In and out-of-state emergencies

Health and Pharmacy Claims 

All health plans offered through OSEEGIB process claims and send Explanations of Benefits (EOB) statements which describe how the claims were processed. The EOB may include information such as the amount billed by the provider, write-off amounts, coinsurance amounts, copays, and the amount of the patient's responsibility. Claims offices also track annual deductibles, out-of-pocket amounts, and services that have plan limitations; e.g., a limited number of chiropractic visits allowed per calendar year. Claims offices may be in-house or contracted out to a third party (TPA).

In the event of an urgent eligibility issue, such as when an employee needs a prescription and their pharmacy rejects the claim for no coverage, please contact your Member Services Representative for assistance.

Be aware that to safeguard your employees’ private health information, you should limit your exposure to their claims information. All the health plans available through OSEEGIB have processes in place that allow an employee and/or adult dependent to authorize the release of their personal health information (PHI). For specific information, contact each plan directly.

Coordination of Benefits (COB) 

If an employee and/or dependents have medical or pharmacy costs that are also covered by another group health plan, the insurance companies coordinate their payments so that the total benefits are not greater than the charges billed, benefits allowed, or the member’s responsibility. This is known as Coordination of Benefits

When a plan needs information about an employee’s or dependent’s other health/pharmacy coverage, a request for information, known as the VOIC (Verification of Insurance Coverage Form) is sent to the primary member. If the member fails to provide the requested information, claims will be delayed or denied for non-compliance.

If you have questions about Coordination of Benefits, contact the specific plan.

Be aware that an employee’s plan through their employer is always primary. If the employee is also covered as a dependent under a spouse’s plan, that plan is secondary.

Different guidelines apply to dependents who are covered under two parents. In the absence of a court order indicating the primary plan, the determination may be based on which parent’s birth month falls earlier in the calendar year, regardless of age. For example, one parent was born in February and the other in April; the plan of the parent born in February will be primary. This guideline is commonly known in the insurance industry as the Birthday Rule.  (See OSEEGIB Rules 360:10-5-87)

In cases where the Birthday Rule cannot be applied, the determination is based on a court order, custody, or the financial responsibility of the dependents.

When there are two group health plans:

• Health claims must be filed with the primary insurance plan first. Once that claim is processed, a claim can then be filed with the secondary insurance. This secondary claim can only be for amounts that were not covered under the primary plan, such as deductibles, coinsurance, or copays. An employee must follow the Coordination of Benefits procedures of both health plans to ensure the smooth processing of claims. Under no circumstances will both plans pay as primary.  (See OSEEGIB Rules 360:10-5-87)
• Most pharmacies are able to electronically file claims with both the primary and secondary insurance plans; however, some pharmacies cannot file a secondary claim electronically. In this case, a paper pharmacy claim must be filed with the secondary plan after the primary insurance plan processes the claim. Employee's can download a Pharmacy Direct Claim for Pre-Medicare.

More Information About Health Insurance 

The specific benefits of each health plan can be found in the Employee Benefit Options Guide, the Vendor Information section of the IC website, or you can contact each plan directly.

Contact Information for Health Insurance