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Medical

Information provided below is for medical benefits in effect prior to July 1, 2011

Click here to see Medical information effective July 1, 2011

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:

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

Cost
What's Covered?
PPO vs HMO
Enrollment
Health Management Program Take Charge! Live Well!
Coordination of Benefits
Health Plan Information
Frequently Asked Questions

Zip code search for health plan service area

Self Service through myOhio.gov

Comparing Costs of Medical Plan Providers (Click to view the links below)

Full-time Employee Deductions

Part-time Employee Deductions

Medical Plan Coverage Differences

Out-of-Pocket Costs of Your Medical Plan Options

In-Network Core Benefits for All Medical Plans

Full-time vs. Part-Time
Full-time employees pay 15 percent of the rate as established by the state.

The percentage that part-time employees pay toward their premium is based on the average hours in active pay status. Average hours in active pay status shall be calculated semi-annually on the basis of 13 pay periods, which start with the pay period that includes January 1 or July 1, respectively.

Hours per bi-weekly pay period
Percent of Premium You Pay
   Less than 40
   40-59
   60-79
   80+
    100%
    50%
    25%
    15%

 What's Covered?

• Allergy Testing and Treatment • Inpatient and Outpatient Services
• Ambulance Service • Maternity - Delivery
• Chiropractic Services • Maternity - Prenatal Care
• Diabetic Supplies • Mental Health and Substance Abuse
• Dietician Services • Physical, Occupational and Speech Therapy
• Durable Medical Equipment • Prescription Medications
• Emergency Room • Preventive Care
• Hearing Loss • Prostheses
• Home Health Care • Radiological Services
• Hospice Services • Skilled Nursing Facility
• Immunizations • Urgent Care
• Infertility Testing • Well Child Care

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.

Enrollment

Enrolling at Hire
You need to enroll by submitting a completed Medical Benefit Enrollment and Change Form FY11 (ADM 4717) for health care coverage to your agency within 31 days of your date of hire, or by using Self-Service through myOhio.gov. If you do not enroll within this time frame, you must wait until the next open enrollment period or if you experience a qualifying event. Documentation will be required for enrolling dependents.  Please go to: das.ohio.gov/EligibilityRequirements for more information.

Medical coverage begins on the first day of the month following the month of your date of hire.

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).  Documentation will be required for enrolling dependents.  Please go to: das.ohio.gov/EligibilityRequirements for more information.

Enrolling/Making Changes Due to A Qualifying Event
Under normal circumstances, you cannot change or drop your coverage until open enrollment unless you experience a qualifying event. Please go to the Qualifying Events Web page at das.ohio.gov/qualifyingevents for more information. Documentation will be required for enrolling dependents.  Please go to: das.ohio.gov/EligibilityRequirements for more information.
 

Health Management Program - Take Charge! Live Well!
Take Charge! Live Well! is a free health and wellness program available to all employees and their spouses enrolled in a state health plan. The program provides tools and services to help members manage their health and feel their best. Services include health assessments, individualized telephone coaching, online lifestyle behavior change programs, online and print health information, worksite health screens, and a nurse advice line. Chronic condition management services are available to enrolled employees and spouses living with asthma, COPD, congestive heart failure, coronary artery disease, and diabetes. Some programs 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.



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., 27th 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  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, 2010 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
Medical Mutual July 1, 2010 Health Plan Description
Group Number: 228000-201
PO Box 6018
Cleveland, OH 44124

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

Paramount
Paramount July 1, 2010 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
The Health Plan July 1, 2010 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, 2010 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.

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 eBenefits enrollment process, or by submitting a Medical Benefit Enrollment and Change Form FY11 (ADM4717)  and required documentation to your agency’s HR Benefits Specialist. Your agency must approve proof of your child’s eligibility. 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.

 

 

 


 

 


 

 

General Contact

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

Driving Directions

Benefits Administration Services Home Page