Department of Administrative Services Human Resources

The State of Ohio provides you with quality, affordable and competitive health care benefits as a part of your total compensation package. You have the flexibility to change your election to best fit your individual or family needs during the spring open enrollment period.

Each state employee has a choice of providers, which is based on where you live and work. The five current state health care providers include:

• Aetna
• Ohio Med
• Paramount
• The Health Plan
• UnitedHealthcare
  

Click the links below to access the information you need quickly.

Enrollment
Cost
What's Covered?
PPO vs HMO
Eligibility
eBenefits
Zip code search for health plan service area
Click here to see Terms and Conditions
Click here to see procedures for enrolling dependent(s) in benefit plans
Conclusion of Coverage
Medicare
Coordination of Benefits
Health Management Program Take Charge! Live Well!
Health Plan Information
Frequently Asked Questions

Comparing Costs of Health Plan Providers

Click here for the chart comparing the cost of your Health Plan option

Click here to view the coverage differences chart.

What's Covered?

 

PPO vs. HMO

What's the difference?
As a state employee, you have the option to select a Preferred Provider Organization (PPO) or a Health Maintenance Organization (HMO). You may select an HMO if it serves the ZIP code(s) in which you live or work. The fundamental difference between the two is that a PPO provides out-of-network coverage while an HMO does not.

For example: If you needed to see a doctor outside of your health care provider's network, you would receive a percentage of coverage if you were enrolled in a PPO, whereas if you were enrolled in an HMO, you would receive no coverage, except for emergency care.

Eligibility

Employee Eligibility
You are eligible for health care benefits if you are a permanent full-time or permanent part-time employee, which includes established-term regular, established-term irregular, a judge or other elected or appointed official.

State of Ohio employee health plans do not contain pre-existing condition exclusions; therefore, coverage is available to you and your eligible dependents regardless of current health or health history.

Employees classified as student help or college interns, or whose appointments are temporary, seasonal, interim or intermittent are not eligible for health coverage.

Married State Employees
When a husband and wife are both employed by the state, both employees cannot carry family coverage for medical, dental or vision. You have the following options:

Both may carry single coverage;

Both may be covered by one family plan; or

One employee may carry family coverage and the other single, but the spouse with single coverage may not be listed as a dependent under the family plan.

Employees NOT Eligible for Coverage
Full-time temporary, appointment types 2, 3, 5
Part-time seasonal, appointment type 6
Intermittent, appointment type 7
Full-time interim internal, appointment type 11, unless eligible prior to interim appointment
Part-time interim internal, appointment types 13
Part-time interim external, appointment type 14
Student or college intern classifications

Eligible Dependents
The following people are eligible to enroll as dependents: 

1. Spouse. Your current legal spouse as recognized by Ohio law.
   
    
2. Unmarried Children under Age 19.
   
   
   • You and your legal spouse's unmarried children (including legally adopted children, children for whom either has been appointed legal guardian and dependent stepchildren and foster children who normally reside with you until the end of the month in which they reach age 19).
     
     
     • You must complete an Affidavit of Dependent Status (ADM 4729) for foster children and for legal guardianship.
       
        
   • Children of divorced or separated parents who are not residing with you but who you are required by law to support, who are under the age of 19.
     
      
3. Unmarried Children over Age 19.
   
   
   • Your unmarried children age 19 or older, who are attending an accredited school and are primarily dependent on you for maintenance and support, are eligible until the end of the month in which they either reach age 23 or cease being a student - whichever occurs first.
     
     
     • Student coverage is not automatic. The State will periodically request proof of school enrollment along with a completed Affidavit of Dependent Status (ADM 4729) form. When you provide this proof, your dependent will continue to be covered. If the requested proof is not provided to the State, their coverage ends on the last day of the birthday month.
       
        
     • To be considered primarily dependent, the dependent must receive the majority of his/her essentials such as food, clothing and shelter from the employee and must be enrolled in an accredited school. Attendance at an accredited school may be either full-time or part-time. Students are permitted to miss one quarter/semester per school year and still retain their coverage.
       
        
     • You must also provide a copy of your most recent tax return showing the child as a claimed dependent.
       
        
   • Under all health plans, coverage for your dependents ends no later than the last day of the month in which they turn 23, unless they have been granted an extension as described below.
     
      
4. Unmarried Children Incapable of Self-Care
   
   
   • Unmarried children of any age who are incapable of self-support due to mental retardation, severe mental illness, or physical handicap, whose disability began before age 23 and who are primarily dependent upon you. When there is an unsuccessful attempt at independent living, a child covered pursuant to this provision may be re-enrolled for coverage, provided that the application is submitted within five (5) years following loss of coverage.
     
     
     • This coverage is not automatic. You must complete an Affidavit of Dependent Status (ADM 4729) and a Request to Extend Limiting Age for Mentally Retarded, Severely Mentally Ill, or Physically Handicapped Dependent Child (ADM 4730) and give these to your payroll or personnel officer. The forms must be completed and returned no later than 31 days prior to the dependent’s 19th birthday, or upon being diagnosed with a disabling condition between the ages of 19 and 23. Periodically, but not more than once a year, proof of continued incapacity and dependence must be provided upon request.
       
        
5. Adopted Children
   
   
   • Adopted children have the same coverage as children born to you or your spouse, whether or not the adoption has been finalized. Coverage begins upon placement/custody for adoption.
     
      
6. Stepchildren
   
   
   • Current stepchildren living in the employee’s home more than 50 percent of the time.
     
      
7. Children of Divorced Parents
   
   
   • Dependents of divorced State of Ohio employees may be enrolled on both parents’ family plan pursuant to a court order or joint custody agreement. However, health plans do not allow duplicate payments for services and may not coordinate benefits. Check details with your plan(s).
     
      
8. Married State Employees with Legally Separate Dependents
   
   
   • In cases of two state employees who are married and who have legally separate dependents, the employee who has coverage as a spouse may be included as a covered dependent as well as children not residing with the employee, but for whom the spouse is required by law to provide health insurance. (e.g. a natural child or children that either state employee had from a prior relationship.)
     
      

Examples of Persons NOT Eligible for Coverage as A Dependent:
 

• A spouse from whom the employee is legally divorced or legally separated
   
• Dependents age 19 to 23 not enrolled in an accredited school who are capable of self-support
   
• A spouse or child currently in the military service
   
• Children age 23 or older who are not disabled
   
• Married children
   
• Same sex partners
   
• Live-in boyfriends or girlfriends
   
• Parents or parents-in-law
   
• Grandchildren (unless employee is the court-appointed legal guardian)
   
• Adults who are not the employee’s or spouse’s child under guardianship of employee (brother, sister, aunt, uncle, etc.)
   
• Common law spouse in which the relationship began after October 10, 1991
   
• A child who is eligible as an employee of the state or who receives health care coverage through their own employment
   
• Current and former stepchildren who do not reside with the employee more than 50 percent of the time
   
• Any other members of your household who do not meet the definition of an eligible dependent
  
   

Enrollment
In general, there are three times at which you may enroll/change your health care benefits:
 

• Enrolling at Hire
  
• Enrolling/Changing During Open Enrollment
  
• Enrolling/Changing Due to A Life Event

1. Enrolling at Hire
You need to enroll by submitting a completed Enrollment Form for health care coverage to your agency within 31 days of your date of hire or your change to permanent status. If you do not enroll within this time frame, you must wait until the next open enrollment period. You may also enroll online using OAKS Self-Service.
Health care coverage begins on the first day of the month following the month of your date of hire and you submit a completed Enrollment Form or enroll using OAKS Self-Service.

2. Enrolling/Making Changes During Open Enrollment
You may enroll, add/drop dependents or change your current elections during the open enrollment period. Open enrollment occurs at least every two years and is usually held in the spring. Coverage becomes effective on the first day of the next benefit period
(typically July 1).

Limited Enrollment Period
During years in which there is no open enrollment, a limited enrollment period will be designated by the Department of Administrative Services. During this limited enrollment period, employees may:

• Add or remove dependents,
  
• Increase their supplemental life insurance amount, and
  
• Enroll for health, dental, vision or supplemental life insurance benefits for the first time.
  
• Leave of Absence
  
• If you are on a leave of absence and coverage has not stopped, you may apply for coverage or change of coverage during the period of open enrollment; however, no change will become effective until the first day of the month following your return to active work status. If you are on disability leave or are receiving benefits from workers’ compensation, changes you make during open enrollment will take effect at the beginning of the next benefit period.
  

3. Enrolling/Making Changes Due to A Life Event
Under normal circumstances, you cannot change or drop your coverage until open enrollment unless you experience a qualifying life event. You can only change your coverage if you submit a completed enrollment form to your agency within 31 days of one of the following events, or - for those changes marked with an asterisk - you may make the changes online using OAKS Self-Service:

• 1*. After marriage, death of a spouse, divorce, legal separation, or annulment, in which case coverage becomes effective the first day of the month following the month of application.
  
• 2*. Birth, adoption, placement for adoption, or death of a dependent, in which case coverage becomes effective with the birth, adoption, or placement of a child or date of death.
  
• 3*. Termination or commencement of employment by the employee, spouse or dependent, in which case coverage becomes effective the first day of the month following the month of application.
  

4. Reduction or increase in hours of employment by the employee (including layoff or reinstatement from layoff), spouse, or dependent, including a switch between part-time and full-time, strike, lockout, or commencement, return to work from an unpaid absence, or change in work site in which case coverage becomes effective the first day of the month following the month of application.

5. Return to work through order of arbitration or settlement of a grievance, or any administrative body with authority to order the return to work of an employee.

6. The employee’s dependent satisfies or fails to satisfy the requirement of the definition of dependent due to attainment of age, student status or any similar circumstance as provided in the Health Plan under which the employee receives coverage.

7. If the plan receives a Qualified Medical Child Support Order (QMED) pertaining to an employee’s dependent, the employee may elect to add or drop the child to the plan depending upon the requirement of the QMED.

8. If an employee, spouse, or dependent who is enrolled in a health plan becomes entitled to coverage (i.e., enrolled) under Part A or Part B of Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928 of the Social Security Act (the program for distribution of pediatric vaccines).

9. If an employee, spouse, or dependent is no longer entitled to coverage (i.e., enrolled) under Part A or Part B of Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928 of the Social Security Act (the program for distribution of pediatric vaccines).
Requests for changes pursuant to Sections (1) through (9) must be supported by proper documentation.

10. The employee either no longer resides or no longer works in the service area of their current health plan. (This is taken directly from the collective bargaining agreement).

Conclusion of Coverage

A qualifying event must occur for health care coverage to end. In general, when a qualifying event occurs, health care coverage ends at the end of the following month, with some exceptions as explained below.

Death of The Employee:
Coverage will end on the last day of the month following the month of death unless there is a request to the agency to end coverage at the end of the month of death.

Termination of Employment:
Coverage will end on the last day of the month following termination of state service unless there is a request to the agency to end coverage at the end of the month of termination.

Loss of Student or Dependent Status:
Coverage will end on the last day of the month in which the student/dependent lost his/her eligibility.

Loss of Eligibility for Current Health Plan:
If you move outside the service area of your health plan, you may elect to enroll in another health plan, or drop health care coverage. If you elect to end coverage, you must notify your agency within 31 days of your loss of eligibility. Coverage will end on the last day of the month following your loss of eligibility for your current plan, unless you request your agency to end coverage at the end of the month of loss of eligibility.

Becoming Eligible for Other Health Insurance:
If you become eligible for other health insurance (ex. through your spouse's employer), your state health insurance will end on the last day of the month following the event unless you request your agency to end coverage at the end of the month of the event.

Voluntarily Dropping Health Insurance:
Health insurance may be dropped without a reason or qualifying event only at open enrollment, and becomes effective at the end of the benefit year (usually June 30th).

Medicare

At age 65, you are eligible to enroll for Medicare benefits. To enroll in Medicare, contact your local Social Security office within one month of reaching age 65. Once you enroll, Medicare will coordinate its coverage with your state health plan.

Coverage Under A State Health Plan
If you are enrolled in any state health plan, that health plan will be the primary carrier and will pay first. Medicare will be the secondary carrier and will pay toward any remaining balance.

If you choose to delay enrollment in Medicare until your group health plan terminates, there is a seven-month enrollment period available beginning with the first day of the first month in which you are no longer enrolled in a group plan. You may enroll any time during that period. There is no premium penalty for this delay in enrollment.

Employees age 65 and older with at least 40 quarters of work credits under Social Security pay no premium for Medicare Part A. Employees do pay the premiums for Part B.

No Coverage Under A State Health Care Plan
If you elect not to participate in a state-sponsored health plan, you will remain eligible for Medicare coverage. Medicare will provide your primary coverage.

Other Retirement Health Care Coverage
If you have coverage under a retirement health insurance plan and are enrolled in a state-sponsored health plan, the state’s health plan will provide primary coverage.

Health Care Coverage for PERS Retirees
Employees who meet all of the following conditions must enroll in a health care plan offered by the state:

Retired from a PERS position and is re-employed in a position covered by PERS;
Receives both a salary from the state and a retirement allowance; and
Appointed as a full-time permanent (appointment code 1), part-time permanent (appointment code 4), full- or part-time internal interim, full- or part-time (appointment codes 11 and 13), 11, 12 interim (appointment code 16), or established term regular (appointment code 17) employee.

Enrollment must occur within 31 days of the date of hire for employees who meet the above criteria and are hired on or after February 9, 1994. Coverage will become effective on the first day of the month following the month in which the employee enrolls. As an example, retirees who enroll in February will have March coverage. Retirees who fail to enroll within the 31-day time frame must wait until the next open enrollment period to choose a health plan. Employees who fail to enroll in a health plan offered by the state and who have no other insurance will have their claims reduced by PERS by those amounts provided or available under the state’s health plans.

A retiree may waive health care coverage only if that employee has coverage from another health plan other than through the state or PERS. The state health care coverage will be primary. PERS health care coverage will be secondary.

Health Management Program - Take Charge! Live Well!
These programs are available to all employees enrolled in a state health plan and their eligible dependents to help members live a healthy lifestyle. Programs include health assessments, telephone coaching, online lifestyle behavior change programs, online and print health information, condition management, worksite health screens, a nurse advice line and preventive care reminders.  Some programs may include a financial incentive for participants.

Click here to learn more about the Take Charge! Live Well! program, including
how to receive your incentive for participating.

Chronic Condition Management
These programs provide education and support for patients to assist in the self management
of chronic conditions, including asthma, cancer, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, obesity, renal disease, end stage renal disease and severe lower back pain. Diabetes supplies are covered at 100 percent with no deductible, copayment or coinsurance for participants in the diabetes chronic condition management program.

Claims Process

Submitting a claim pertains to employees enrolled in Ohio Med only

Network Providers
If you receive services from a network provider, the provider will submit claim forms for you. Network providers file claims directly with Medical Mutual. Medical Mutual sends payment to the provider directly.

To ensure fast claim filing, you may wish to contact Medical Mutual to determine if the health care service is covered. Show your identification card to the provider and determine if the provider is in the Ohio Med network. Ask the provider to file the claim on your behalf. Remember, not all services are covered by this or any insurance plan. Ineligible expenses are your responsibility.

Non-Network Providers
You are responsible for filing claims for services received by non-network providers. You also will 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 services received at non-network or non-participating providers will be made to you. You must pay the provider. (However, for persons enrolled in the Traditional plan, Medical Mutual does pay the provider directly).

Explanation of Benefits
After the claim is paid, Medical Mutual 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 EOB information. Make payment based on a bill you receive from your provider.

Claims Appeal Process - for employees enrolled in any of the state's health plans

Keep copies of all your bills, claims and correspondence. In some cases, a claim may be denied. 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; however, check your health plan's description for details.

Department of Administrative Services Appeal
If all levels of appeal with your health plan have been exhausted and you disagree with the decision, you can file a complaint and/or request a benefit determination from the Department of Administration Services.

Submit a written request within 60 days of receiving your health plan's final written decision and supply the documentation from earlier appeals. Send your request and documentation to:

Benefit Appeal
Benefits Administration Services
30 East Broad St., 28th Floor
Columbus, OH 43215

A written decision will be given within 60 days after you submit your request.

Coordination of Benefits

You and your family members may have coverage under more than one health plan. The health plans include a coordination of benefits (COB) provision to eliminate duplication of payment for services. However, there is no COB for prescription medications.

Under COB, the plan that pays first is the primary plan.
The secondary plan pays after the primary plan.
The result is that both the state and the other insurance company pay a fair share but the combined payments by both plans will not exceed the maximum allowable reimbursement.

How COB Works
If you have coverage under more than one plan, you have a responsibility to help make COB work for you. When you incur charges, you need to submit all bills to the carrier you believe to be primary and write the name of the other carrier on the claim form. The carriers will make determinations about which is primary and which is secondary.

There is no coordination against the following kinds of coverage:

Group hospital indemnity coverage that pays less than $100 per day
Individual (not group) policies or contracts
Medicaid
School accident coverage
Some supplemental sickness and accident policies

Determining Who Is Primary
To decide which health care plan is primary, your health plan has to consider both the coordination of benefits provisions of the other health care plan and which member of your family is involved in the claim.

The primary health care plan will be determined by rules established by the plan:

Your Health Plan as Primary
Your plan will pay the full benefit provided by your contract as if you had no other coverage.

Your Health Plan as Secondary
When your plan is the secondary plan it will make payments based on the balance left, if any, after the primary health care plan has paid. Your plan will pay no more than that balance up to the amount it would have paid had it been primary. In some cases, this may be nothing at all.

Your plan will pay only for health care services that are covered under this contract and will pay no more than the “allowable expense” for the health care involved.

If You Have a COB Dispute
If you believe that a claim was not paid properly because of COB, you should first attempt to resolve the problem by contacting your health plan. If you still are dissatisfied, and would like instructions on filing a consumer complaint, you may call the Ohio Department of Insurance at 614.644.2673 or 800.686.1526.

Enforcement of Provisions
Your health plan will coordinate your benefits, if you properly inform them of your coverage under any other health care plan. Your plan is required to determine if and to what extent you are covered under any other health care plan.

Through the utilization of your health care benefits, you and/or your dependent will be required to provide any requested information to your health plan to process the claim that has been incurred. Your health plan also may release or obtain necessary information without consent from your dependent.”

Facility of Payment
Your health plan will not pay a provider bill that has already been paid by the other health care plan. If payment that should have been made by your plan is made under any other health care plan, your plan will pay whoever paid under the other health care plan. Your health plan will determine the necessary amount under the provision, and any amount paid by your plan in this circumstance is considered a benefit under the plan. Your plan is discharged from liability to the extent of such amounts paid for covered services.

Your Health Plan’s Right of Recovery
If your plan pays more for covered services than this provision requires, it has the right to recover the excess from anyone to or for whom the payment was made. You agree to do whatever is necessary to secure your health plan’s right to recover excess payment.

Health Plan Information

Below are links to the Web site, address, phone number and health plan description for each health plan provider. The health plan description is a detailed explanation of your benefits. If you have questions about this information, please contact your health plan at the phone number below - be sure to identify yourself as a state of Ohio enrollee.

Aetna
Aetna July 1, 2009 Health Plan Description
Group Number: 619316
Aetna
7400 W. Campus Road
New Albany, OH 43054

1-800-520-4785
Aetna's Web Site

Ohio Med
Ohio Med Health Plan Description -- Updated 10/1/09
Group Number: 228000-201
PO Box 6018
Cleveland, OH 44124

1-800-822-1152
Ohio Med's Web Site

Paramount
Paramount July 1, 2009 Health Plan Description
Group Number: 030291
1901 Indian Wood Circle
Maumee, OH 43537

1-800-462-3589
Paramount's Web Site
Please note that any behavioral health providers, dentists, and optometrists listed in the online directory are not available to State employees.

The Health Plan
July 1, 2009 Description Coming Soon
The Health Plan July 1, 2008 Health Plan Description
Group Number: 0141
52160 National Rd. East
St. Clairsville, OH 43950

1-800-624-6961
The Health Plan's Web Site

UnitedHealthcare
UnitedHealthcare July 1, 2009 Health Plan Description
Group Number: 702097
9200 Worthington Rd.
Westerville, OH 43082
1-877-442-6003
UnitedHealthcare's Web Site

  
Frequently Asked Questions

When can I enroll, terminate or make changes to my medical benefits?

There are three instances when employees can enroll, terminate from or make changes to their benefits. These times are:

• Within the first 31 days of employment
  
• Within 31 days of a life status event or job change
  
• During the annual open enrollment period
  

When can I change medical plans?

You may change providers either during open enrollment, or within 31 days of a change in your place of employment or home address outside of your current plan’s service area.

How do I use my benefits?

Ask the health care provider you use (physician, hospital, laboratory, etc.) if they are in your plan’s provider network.  If they are, present your plan identification card at the time of service.  You will pay any co-payment at the time of service, such as a $20 office visit co-pay or a $75 emergency room copay (see your plan’s summary description for more details).
Your plan will pay your provider and send you an explanation of benefits (EOB) explaining what has been paid and what, if anything, has not been paid and is your responsibility.
Your provider will bill you for any amount remaining for which you are responsible.

Who are my eligible dependents?

Your current spouse (not an ex-spouse), your unmarried children or step-children under the age of 19 (or up to age 23 if a student). Other dependents may be covered under certain conditions.

I have a new child – how do I add him/her to my insurance?

Your newborn or adopted child may be added within 31 days of the event by using the OAKS Self-Service Benefits enrollment process, or by submitting a Medical Benefit Enrollment and Change form (ADM4717) to your agency’s HR Benefits Specialist. Your agency must approve proof of your child’s eligibility, through either a birth certificate or an adoption certificate. If you do not enroll your child or submit proof of eligibility within 31 days of his/her birth/adoption, you may add him/her during the annual open enrollment period.

Do I need to be pre-approved for any services, or are they covered when
recommended by my physician (ex: blood work)?

The following procedures must be pre-certified by your physician:

• Magnetic Resonance Imaging (MRI)
  
• Positron Emission Tomography (PET)
  
• Magnetic Resonance Angiography (MRA)
  

 
If your physician is a network provider, he/she will seek pre-approvals for you, should they be needed.

Are prescription medications covered?

Yes, prescription medications are a covered benefit. You will pay the least for generic drugs, more for name-brand drugs that are on the list of approved drugs, and you will pay the most for those brand-name drugs that are not on the plan’s list of approved drugs.

What is a Deductible?

A Deductible is the amount you will have to pay before the plan begins to pay.