Web Content Viewer
Actions

Compare the Ohio Med plan options

State of Ohio Medical Plan: Ohio Med

All employees family members who are enrolled in the State of Ohio medial plan are in the Ohio Med medical plan.

Medical Plan Options:

  • Ohio Med PPO
  • Ohio Med HDHP
  • Ohio Med NN (available beginning July 1, 2022)

Employees enrolled in the State of Ohio medical plan can choose between either the Ohio Med PPO or the Ohio Med HDHP medical plan option for their medical coverage.

What is covered in each plan design is similar. What is different is how the plan is administered as well as costs.

What is a preferred provider organization?
A preferred provider organization (PPO) is a medical plan that offers benefits at both in-network and out-of-network levels with set copay amounts for certain services. When you enroll in the Ohio Med PPO, you may visit any doctor and receive benefits. However, the coverage amount is greater when you use in-network providers.

What is a high deductible health plan?
A high deductible health plan (HDHP) is a medical plan that offers benefits at both in-network and out-of-network levels with a higher deductible and out-of-pocket maximum than the PPO plan. The contribution is usually lower, but you pay more health care costs before the medical third-party administrator starts to pay its share. The HDHP comes with a Health Savings Account (HSA), which allows you to pay for certain medical expenses with money free from federal taxes.

Employees enrolled in the Limited Purpose FSA can still enroll in the Ohio Med HDHP.

Exclusions from the HDHP: If you or your spouse are currently enrolled in a Flexible Spending Account – Health Care Spending Account for this calendar year, neither of you are eligible to enroll in the Ohio Med HDHP. This also applies if you have a carryover balance as of Dec. 31. You also cannot enroll in the HDHP if you are currently enrolled in Medicare or Tricare. You may enroll or remain enrolled in the Ohio Med PPO.

Ohio Med PPO

Ohio Med HDHP

  • This plan is a preferred provider organization (PPO).

  • Has a higher employee contribution, but a lower deductible. Members must pay the full amount until the deductible is met.

  • Copay amounts are set for medical services such as a visit to the doctor or hospital, and prescriptions.

  • Prescription costs are not combined with medical to meet your out-of-pocket maximum.

  • There is a separate $3,500 single or $7,000 family out-of-pocket maximum that must be met before prescription costs may be paid at 100%.

  • Each person covered in a family plan must meet the individual deductible or the combined family deductible, whichever occurs first, before the plan begins to pay.

  • The high deductible health plan (HDHP) includes a health savings account (HSA) with a state contribution to your account.

  • Has a lower employee contribution, but a higher deductible. Members must pay the full amount until the deductible is met.

  • Initial expenses can be paid by you using the HSA, or you could be reimbursed after a claim has been submitted.

  • Neither you nor your spouse can currently be enrolled in or have a carryover balance from the previous calendar year in any Flexible Spending Account – Health Care Spending Account

  • You can enroll in a Limited Purpose Flexible Spending Account.

  • Prescription costs are combined with medical to meet your out-of-pocket maximum.

  • If you are in a family plan, the plan will begin to pay only after the entire family deductible has been met.

Which plan is right for your family? 

Ohio Med PPO could be the best option if you:

Ohio Med HDHP could be the best option if you:

  • Prefer to know in advance the cost of your copayments, including doctor visits, prescriptions, hospital stays and medical services.
  • Anticipate a high-cost medical expense, such as surgery.
  • Have a chronic condition or a need for frequent doctor visits.
  • Take a high-cost specialty drug or take multiple prescriptions.
  • Prefer to actively manage your health care spending by regularly comparing costs and saving for future medical expenses.
  • Rarely need doctor visits.
  • Have the ability to pay, up front, the full deductible and out-of-pocket costs for medical expenses at the time that you incur these costs.
  • Are able to contribute to your Health Savings Account and prefer to save for future medical expenses including expenses after you retire.

IMPORTANT POINTS ABOUT THE HDHP

The deductible must be reached first before the plan pays toward any of your medical, pharmacy or behavioral health costs. If you have family coverage, the plan will begin to pay only after the entire family deductible has been met. This is especially important to understand if a major medical expense or a high-cost specialty drug needs to be covered within the first few days, weeks or months of the Ohio Med HDHP plan taking effect.

For an in-network example, if your medical coverage would begin on Aug. 1 and an accident would occur on Aug. 4, you should ensure that you can pay the full out-of-pocket cost (including the deductible) for the plan option that you selected: either single coverage at $3,500 or family coverage at $7,000. After you meet your deductible (either $2,000 or $4,000 in-network), the plan would cover expenses at 80%. After the full amount of the out-of-pocket maximum is paid, the plan would cover expenses at 100%.

Specialty drugs could have a high cost (even into the thousands of dollars). If you or a dependent already are taking, or could be taking, a specialty drug, use a cost comparison tool at OptumBank.com/myOhioHSA to determine which is the best medical plan for you. Your deductible is used to pay for the specialty drug before the plan will pay.

Enrollment in the HDHP is online only. Because the federal guideline for the HSA requires a personal bank account (provided by Optum Bank, which is managed by you), and because contributions to the HSA are determined by you, enrollment in the Ohio Med HDHP only can be completed online through myOhio.gov.

 

How HDHP Claims are Paid

Doctor’s Visit

You go to the doctor.

Medical Claim

The doctor sends a claim to your medical third-party administrator with a list of services you received. The claim is reviewed and processed based on your plan benefits.

Plan Pays

Your medical third-party administrator lets the doctor know how much is being paid for covered medical services and how much, if anything, you have to pay.

Explanation
of Benefits

Your medical third-party administrator sends an explanation of benefits to you. It’s not a bill; it’s a summary of how the claim was processed and what, if anything, you owe the doctor.

Medical Bill

If you owe the doctor any money, the doctor will bill you for it and you can pay the doctor directly.

HSA

You can use any available funds in your HSA to pay the doctor if you have money in your HSA.

 

How PPO Claims are Paid

Doctor’s Visit

You go to the doctor.

Medical Claim

The doctor sends a claim to your medical third-party administrator with a list of services you received. The claim is reviewed and processed based on your plan benefits

Plan Pays

Your medical third-party administrator lets the doctor know how much is being paid for covered medical services and how much, if anything, you have to pay.

Explanation
of Benefits

Your medical third-party administrator sends an explanation of benefits to you. It’s not a bill; it’s a summary of how the claim was processed and what, if anything, you owe the doctor.

Medical Bill

If you owe the doctor any money, the doctor will bill you for it and you can pay the doctor directly.