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The State of Ohio provides you with quality, affordable and competitive medical benefits as a part of your total compensation package.


Medical Third-Party Administrators

As of July 1, 2016, the medical third-party administrators for the Ohio Med PPO – the state’s preferred provider organization – are: Aetna, Anthem and Medical Mutual of Ohio.

Finding your doctor is as easy as 1-2-3

Whether you are looking for your doctor or checking if a provider (doctor, hospital, urgent care, etc.) is in your network, follow these steps:
Go to das.ohio.gov/medicalTPA:
1. Identify your medical third-party administrator (Aetna, Anthem or Medical Mutual) by locating the first three digits of your home ZIP code on the chart.
2. Click the provider guide link for your medical third-party administrator.
3. Follow the instructions to access the provider information you need.

About Medical Coverage

Medical Coverage

What is Covered

Allergy testing and treatment;
Ambulance service;
Breastfeeding support, supplies and counseling;
Chiropractic services;
Diabetic supplies;
Dietitian services;
Durable medical equipment;
Emergency room;
Hearing loss;
Home health care;
Hospice services;
Immunizations;
Infertility testing;
Inpatient and outpatient services;
Maternity - Delivery;
Maternity - Prenatal care;
Mental health and substance abuse;
Physical, occupational and speech Therapy (Includes coverage for Autism Spectrum Disorder);
Prescription medications;
Preventive care;
Prostheses;
Radiological services;
Skilled nursing facility;
Urgent care; and
Well child care.

This list is not all-inclusive. Refer to the plan documents for further details.

Medical Deductions

Out-of-Pocket Costs

Preventive Care Information

Third-Party Administrator Information

Below are links to the third-party administrator websites, addresses, phone numbers and plan descriptions for the two third-party administrators. The plan description is a detailed explanation of your benefits. If you have questions about this information, please contact your third-party administrator at the phone number below -- be sure to identify yourself as a State of Ohio enrolled member.

Aetna
Aetna Plan Description - July 1, 2017 - June 30, 2018
Aetna Plan Description - July 1, 2016 - June 30, 2017
Group Number: 285507
1-800-949-3104
Aetna's State of Ohio employee portal

Anthem
Anthem Plan Description - July 1, 2017 - June 30, 2018
Anthem Plan Description - July 1, 2016 - June 30, 2017
Group Number: 004007521
1-844-891-8359
Anthem's State of Ohio employee portal

Medical Mutual of Ohio (MMO)
Medical Mutual of Ohio Plan Description - July 1, 2017 - June 30, 2018
Medical Mutual of Ohio Plan Description - July 1, 2016 - June 30, 2017
Group Number: 228000
PO Box 6018
Cleveland, OH 44124
1-800-822-1152
Medical Mutual Of Ohio’s State of Ohio employee portal

UnitedHealthcare (UHC)  Coverage ended June 30, 2016
UnitedHealthcare Plan Description - July 1, 2015 - June 30, 2016
Group Number: 702097
9200 Worthington Rd.
Westerville, OH 43082
1-877-440-5977
UnitedHealthcare’s State of Ohio employee portal

Summary of Benefits and Coverage

A requirement of the Affordable Care Act, the Summary of Benefits and Coverage document is a concise four-page document that details simple and consistent information about health plan benefits and coverage. 

Click here to download the Summary of Benefits and Coverage.

Enrollment

Enrollment

Enrolling at Hire
You can enroll by using myOhio.gov and clicking on myBenefits or by submitting a completed Benefit Enrollment/Change Form (ADM 4717) for medical coverage to your agency within 31 days of your date of hire. If you do not enroll within this time frame, you must wait until the next open enrollment period or until you experience a change in status/qualifying event. Documentation will be required for enrolling dependents. For information, visit das.ohio.gov/EligibilityRequirements.

Medical coverage begins on the first day of the month following the month of your date of hire, regardless of when your start date falls and regardless of when your 31-day deadline falls.

Enrolling/Making Changes During Open Enrollment
You may enroll or add/drop dependents during the open enrollment period. You can enroll by using myOhio.gov and accessing myBenefits or by submitting a completed Benefit Enrollment/Change Form (ADM 4717) for medical coverage to your agency during the open enrollment period. Coverage becomes effective on the first day of the next benefit period, which begins July 1. Documentation will be required for adding dependents. For information about dependent eligibility requirements, visit das.ohio.gov/EligibilityRequirements.
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Enrolling/Making Changes Due to a Change in Status/Qualifying Event
Under normal circumstances, you cannot change or drop your coverage until open enrollment unless you experience a change in status/qualifying event. Click here for more information. You can enroll by using myOhio.gov and accessing Self-Service or by submitting a completed Benefit Enrollment/Change Form (ADM 4717) to your agency within 31 days of the event. Documentation will be required for any changes. For information about dependent eligibility requirements, visit das.ohio.gov/EligibilityRequirements.

Enrollment in Health Management Programs

Health Management, Prescription Drug and Behavioral Health Programs
When you enroll in the medical plan, you also will be enrolled in the Take Charge! Live Well! -- the state's health and wellness program, the prescription drug program and the behavioral health program.

Click the links below to access details about these benefits programs.
Take Charge! Live Well! 
Prescription Drug
Behavioral Health

Benefits ZIP Code Zone Chart

 

Part-time Permanent vs. Part-time Temporary Employee Benefits

Effective July 1, 2015:

Part-time Permanent Employees

  • Part-time permanent employees’ premium tier will be determined annually rather than semi-annually.
  • The percentage that part-time employees pay toward their premium is based on the average service hours in an active pay status. Average service hours in an active pay status shall be calculated over a 12-month period (Standard Measurement Period), which starts with the first pay period in May through the last pay period in April.
    • All part-time permanent employees working an average of 30 or more hours a week (over a 12-month period) will be eligible for the full-time deduction tier, or 15 percent.
    • All part-time permanent employees working an average of 29.99 or less hours a week (over a 12-month period) will be eligible for the 50 percent tier.
    • All part-time permanent employees working an average of 19.99 or less hours a week (over a 12-month period) will be eligible for the 100 percent tier.




Part-time Temporary Employees

  • The State of Ohio is required to offer medical care coverage only, per the ACA, to all part-time temporary employees who average at least 30 hours of service per week throughout a twelve-month measurement period (Standard Measurement Period). 
  • Part-time temporary employees are those employees typically hired as interns, intermittent employees, and external interim employees. This does not include Americorps or contingent workers.
    • Existing employees who were hired before April 5, 2014, and who averaged 30 work hours or more will be notified by DAS of their eligibility for medical coverage. Those who elect medical coverage will have coverage from July 1, 2015 through June 30, 2016, or until they terminate their service with the State of Ohio.
    • Employees who are hired with a reasonable expectation of averaging 30 hours or more per week will be eligible to enroll for coverage upon hire. Coverage is effective the first of the month following the hire date and cannot be terminated until the 12 months expires or the employee leaves state service.
    • Employees who are hired with a reasonable expectation of averaging 29 hours or less per week will be not be eligible at the time of hire and will instead be measured over a twelve-month period. The twelve-month measurement period for all newly hired part-time temporary employees is called the initial measurement period.
      • The initial measurement period begins the first full pay period after the first pay period with one or more hours of service credited.
      • After the initial measurement period, if the average service hours are 30 or more per week, the employee will be offered the opportunity to enroll the first of the month following the end of the initial measurement period. Part-time temporary employees meeting this criteria will be placed into the 15 percent tier. 

Claims

Claims Process

In-Network Providers
If you receive services from a network provider, the provider will submit claims for you. Network providers file claims directly with your third-party administrator (TPA) and then the third-party administrator sends payments directly to the providers. 

To ensure fast claim filing, you may wish to contact your third-party administrator to determine if the medical service is covered. Show your identification card to the provider and determine if the provider is in the Ohio Med PPO network. Remember, not all services are covered by the Ohio Med PPO plan. Ineligible expenses are your responsibility.

Non-Network Providers
You may be responsible for filing claims for services received by non-network providers. You also may be responsible for filing claims for services for which you have paid directly. 

Use a separate claim form for each person for whom you are filing a claim. Submit the original bills with the claim form and be sure to keep copies for your records. Add your identification number to each bill to speed processing. 

Payments for eligible services received at non-network or non-participating providers will be made to you by check. You must then pay the provider.

Explanation of Benefits

After the claim is paid, your third-party administrator will send you an Explanation of Benefits (EOB) which describes the benefits received, lists the payments to the provider and identifies expenses, if any, for which you are responsible. However, do not make payment to providers based on the explanation of benefits information. Make payment based on a bill you receive from your provider.

Claims Appeals

Keep copies of all your bills, claims and correspondence. In some cases, a claim may be denied by your third-party administrator. You have the right to appeal that decision. If you wish to appeal a denied or reduced claim, there are some specific steps to take. Refer to your third-party administrator plan description for details on appealing claims.

Coordination of Benefits

You and your family members may have coverage under more than one medical plan. The medical plans include a coordination of benefits provision to eliminate duplication of payment for services. However, there is no coordination of benefits for prescription medications. Refer to your plan description for more details on the coordination of benefits.

General Contact

Department of Administrative Services
30 East Broad Street, 27th Floor
Columbus, Ohio 43215
614-466-8857 Local
800-409-1205 Toll Free

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