PEBB 2014 Frequently Asked Questions

PEBB Open Enrollment and Choosing Group Health

Why should I choose Group Health?
Options, quality, and convenience — it's how Group Health makes your health care better. You have the freedom to choose your own doctor, from the more than 1,100 providers at Group Health Physicians to the more than 9,000 community doctors and 42 hospitals statewide.* You also get the quality care you deserve, including more time with your doctor.

Better health care also means making it convenient for you. So every Group Health Medical Center has lab, X-ray, and pharmacy services all under one roof. Get access anytime, anyplace with our personal online services on your computer or on your smartphone with our new mobile app. Either way, you can make appointments, e-mail your doctor, see your test results, and more whenever you get care at a Group Health Medical Center.

Doctors and Care

How do I find out if my doctor is in Group Health's network of providers?
You can use our Provider Directory to find available physicians in your area or to see if your current personal doctor is available through Group Health. In addition to the 1,300 plus Group Health Physicians, our online Provider Directory also lists the names of over 9,000 contracted doctors.**

How do I choose a personal physician, and how can I change physicians?
To find a provider, check our website for the most current information, refer to our Provider Directory, or call Customer Service at 1-888-901-4636. Our Customer Service representatives can help you choose a doctor based on his or her location, special interests, gender, or other factors that are important to you. Also remember that each family member may choose a different provider. If for any reason you wish to change doctors, you can at any time.

How can I see a specialist?
With your Group Health plan, you can choose from 500 specialists in over 75 specialties* — most without a referral. These specialists are located at our Group Health Medical Centers. To find out which specialists are available, please call Customer Service at 1-888-901-4636 or speak to your personal physician. If you wish to see a specialist who does not practice at a Group Health Medical Center, talk with your personal physician about a referral.

Is acupuncture or massage therapy considered specialty care?
The PEBB plans cover a limited number of acupuncture, naturopathy, and chiropractic visits without requiring a referral from your personal physician or primary care provider. Massage therapy services require a referral from your personal physician if he or she determines the services are medically necessary.

How do I access routine care?
Routine care is available at any Group Health Medical Center or facilities in our contracted network. Please refer to your Provider Directory or our website for specific phone numbers for the facility of your choice.

How do I access urgent care?
Six of our medical centers have Urgent Care Centers, most with evening, weekend, and holiday hours including Bellevue, Everett, Olympia, Seattle (Capitol Hill), Silverdale Medical Center, and the Tacoma Medical Center. Urgent Care Centers at the Bellevue Medical Center, Capitol Hill Campus in Seattle, and Tacoma Medical Center are open 24 hours a day, seven days a week.

For urgent care during business hours, call your personal physician's office or the Consulting Nurse Service. For urgent care after business hours, on weekends, or on holidays, call the Consulting Nurse at 206-901-2244 for the Seattle area. For all other areas in Washington state, call 1-800-297-6877. The nurse will listen to your concerns and direct you to the most appropriate care.

How do I access emergency care?
In a life-threatening emergency, call 911 or your local emergency number. If you are unable to do so, ask someone to call for you or to take you to the nearest emergency care facility. You may go to any hospital in your area for emergency care. Remember that you may save money if you go to an emergency room at any of our contracted hospitals if possible. Please refer to your Provider Directory or our website for specific phone numbers for the facility of your choice.

What if I need care on Saturday?
In addition to Group Health Urgent Care Centers, several Medical Centers, including Bothell (Northshore), Burien, Federal Way, Lynnwood, Renton and Seattle (Northgate), offer limited services on Saturdays for minor injuries or illnesses that require immediate attention. These medical centers offer appointments on Saturdays from 9 a.m. to 12:30 p.m.

How do I know if I need urgent or emergency care?
When you want care advice or need to know if you should get immediate medical attention, Group Health's Consulting Nurse Service can help 24 hours a day. In the Seattle area, call 206-901-2244. For all other areas in Washington state, call 1-800-297-6877.

Use emergency care for sudden, unexpected medical conditions that, in the reasonable judgment of a prudent lay person, would endanger a person's life or seriously harm the person's health if not treated immediately by a licensed medical professional. Emergency medical conditions include:

  • Suspected heart attack or stroke
  • Sudden or extreme difficulty breathing
  • Bleeding that will not stop or deep cuts
  • Major burns
  • Seizures
  • Sudden and severe headache or abdominal pain
  • Poisoning or suspected poisoning

If someone in my family gets a serious illness and needs hospitalization, where will they go if I am a Group Health member?
Group Health's priority is putting patients first — which always means giving you the best care possible. If you or anyone in your family has a serious illness and needs hospitalization, you can rest assured that Group Health has amazing partners in care including Seattle Children's Hospital, Overlake Hospital Medical Center and Virginia Mason Medical Center. You also have access to Group Health Cancer Care, supported by our affiliation with Seattle Cancer Care Alliance. Your personal physician will help coordinate your care to the place that best suits your needs.

How do I access routine care, urgent care and emergency care when I'm away from home?
When you're traveling, routine and urgent care is available at any of Kaiser Permanente's facilities. In the case of a life-threatening emergency, call 911 or the local emergency number where you are visiting. You are covered for emergency care worldwide. If you are admitted to the hospital, you or a family member must call the Emergency Notification Line at 1-888-457-9516 within 24 hours, or as soon as reasonably possible.

What services are offered at Group Health Medical Centers?
You can get one stop services at all of our 25 Group Health Medical Centers where you'll find that in addition to seeing your doctor, you can get lab tests, X-rays, and pharmacy services — all under one roof.

It seems Group Health is very proactive about preventive care. Why and what resources are available to me?
At Group Health, we believe in getting healthy and staying that way. That's why we offer an array of wellness resources and put a priority on preventive care so you can avoid problems before they start. From your annual wellness visit and recommended screenings, to a proactive Health Profile questionnaire, to access to Health Coaching 24/7 for additional support,  we provide you with a variety of clinical help so that you can be your healthiest self. We also have tobacco cessation programs, classes and support groups, and a whole lot more.

I've read about a concept that Group Health uses called medical home. What is it?
The heart of care at Group Health Medical Centers is your personal relationship with your doctor and your health care team. That's why we spent the past two years testing an advanced model for primary care, that we call Medical Home. It's designed to give you expanded primary care that is personalized, focuses on prevention, actively involves you in making decisions about your care, and helps coordinate all your care and get your health needs met. And with electronic medical records everyone on the health care team, including you, can have assess to the vital information they need to make important decisions.

Prescriptions

How and where do I fill my medical prescriptions?
Your medication prescriptions can be filled at any Group Health Medical Center or you can find additional contracted pharmacies in your Provider Directory. You can also conveniently refill your prescriptions online and have them delivered to your home with no shipping fees through our mail-order service.

I am on a specific prescription. How is this transferred or handled?
If you are a new patient and are seeing a Group Health physician for the first time, you may be taking medicine prescribed by a non-Group Health doctor. Please make an appointment to review your medications with your new Group Health personal physician.

I hear there is a Value Tier for the Prescription Drug benefit. Which drugs are included on this tier?

  • Diabetes: Metformin, glipizide, glimepiride, glyburide, insulin NPH
  • Hyperlipidemia: Simvastatin, lovastatin, pravastatin
  • Heart failure: Carvedilol, metoprolol XL, spironolactone
  • Hypertension: Hydrochlorothiazide, chlorthalidone, lisinopril, enalapril, captopril, ramipril, lisinopril/HCTZ, amlodipine, verapamil, diltiazem, metoprolol IR, atenolol

Transferring Care and Medical Records

If I have an ongoing medical condition, how will the transition of care be coordinated?
Members with transitional care needs are encouraged to contact a Customer Service representative who will help in transitioning and coordinating the care of new members. Please call Customer Service at 1-888-901-4636, Monday through Friday, between 8 a.m. and 5 p.m.

How do I get my medical records transferred?
You may request your personal medical record from your previous physician. Your previous physician may request proof of identification or a signature to release your medical records. You may bring your files to your newly selected physician or you can request that the files be sent directly to the facility of your choice.

Online Services and Mobile App

I've been hearing about time-saving online services that Group Health provides. What's available?
MyGroupHealth for Members lets you refill prescriptions, create your own Health Profile, and browse more than 5,000 health care topics. You can also better manage your health care costs by tracking your spending toward deductibles and out-of-pocket expenses. And, when you receive care at a Group Health Medical Center, MyGroupHealth for Members allows you to securely e-mail your doctor, get online test results, view your online medical record, check your child's medical record (through age 12), and more. See our online tour for more information.

I also heard Group Health has a smartphone app. What services are available through my phone?
If you are registered with MyGroupHealth and receive your care at Group Health Medical Centers, you can now do many things that you can via MyGroupHealth anytime, anywhere — with our smartphone app. For added convenience, this app includes a host of innovative features to easily connect you to the Consulting Nurse, check lab and pharmacy wait times at your nearest Group Health Medical Center, map directions to our medical facilities, or use an interactive Symptom Checker.

Benefit Changes and Enrollment

How will my benefits change for 2014?

  • The annual deductible, all copays, and all coinsurance for covered services will apply to the annual out-of-pocket maximum. (See "What doesn't count toward the annual out-of-pocket maximum.")
  • Acupuncture: Visit limit is eliminated for treatment of chemical dependency.
  • Cochlear implants - outpatient: You pay $15 copay per primary care office visit, and $30 copay per specialist office visit (deductible applies to both).
  • Cochlear implants - Inpatient: You pay $150 copay up to $750 per person per admission (deductible applies).
  • Outpatient services: The plan will cover routine services provided during a clinical trial; your cost-sharing applies based on service.
  • Prescription drugs: The plan will cover preferred prescription drugs provided during a clinical trial; your cost-sharing applies based on drug tier.
  • Rehabilitation: No visit limits for rehabilitation due to cancer, pulmonary, respiratory disease, or other chronic conditions.
  • Group Health CDHP only: Preventive care under the extended network is not covered, except for screening mammograms (annual deductible and coinsurance apply).

What doesn't count toward the annual out-of-pocket maximum?
The annual out-of-pocket maximum is the most you pay in a calendar year. Once you have paid this amount, the plans pay 100 percent of allowed charges for most covered benefits for the rest of the calendar year.

These costs do not apply toward your annual out-of-pocket maximum:

  • Monthly premiums
  • Charges above what the plan pays for a benefit
  • Charges above the plan's allowed amount paid to a provider
  • Charges for noncovered services or treatments
  • Coinsurance for non-network providers

See our website for all of your 2014 plan details.

 

How do I enroll in a Group Health plan?
Visit the PEBB website where you can select My Account (under the My PEBB header) to make a plan change online. Or you can download and print a form from PEBB's Get a Form page.

Medicare

I'm going to be eligible for Medicare soon. What do I need to do?
When you receive your Medicare card, send a copy of it to the Public Employees Benefits Board indicating the effective dates of your Medicare Parts A & B coverage. You will also need to send a Medicare Advantage election form to Group Health. You won't need to enroll in Part D of Medicare, since your PEBB plan provides comparable prescription drug benefits.

Dependent Children and Student Dependents

I've heard the rules have changed regarding how long a dependent child can be covered. What are the new rules?
Beginning January 1, 2011, national health reform requires PEBB medical plans to cover married and unmarried children up to age 26 in the same way PEBB currently covers dependent children. These children will not need to be students or IRS dependents to qualify for PEBB coverage. PEBB dependents who lose eligibility may qualify for continued coverage; contact the Public Employees Benefits Board for more information. If your dependent no longer has PEBB coverage, please call 1-800-358-8815 to learn about Group Health's Individual and Family plans.

What's the coverage for out-of-area student dependents?
As of January 1, 2011, dependent students who live outside the Group Health service area have the same coverage as any out-of-area member, which is emergency/urgent care only. Other services will be covered when they are obtained within our service area. If your student dependent lives in a Kaiser service area, they can get routine care at a Kaiser Medical Center.

Classic and Value Plan Differences

 

What's the difference between Group Health's Classic and Value plans?
Our Value plan is designed to keep your monthly premium low. For 2014, Value plan rates are just $65 per month for a single employee, $140 for employee and spouse, $114 for employee and children, and $189 for families.* As a Value plan member, you'll get all of the same valuable services as the Classic plan, while spending less on your monthly premiums. A competitive annual deductible and copays paired with fully covered preventive care services provide you with an affordable medical plan. Learn more about the Value plan rates and benefits.

Our Classic plan for PEBB employees offers lower copayments and a lower annual deductible than the Value plan, but it has a higher monthly premium.  Preventive care services are still covered in full. Learn more about Classic plan rates and benefits.

CDHP and HSAs


Can you tell me more about CDHP plans?
The CDHPs offer a low monthly premium, balanced with a higher deductible and out-of-pocket maximum. However, members can use funds in their Health Savings Account (HSA) to pay for many out-of-pocket costs (including deductibles), or allow HSA savings to grow for future medical expenses. When you enroll in a CDHP, your employer or the PEBB Program contributes money into your HSA on a prorated basis. This will add up to $700.08 annually for a single subscriber, or $1400.04 annually for a subscriber and one or more covered dependents. The entire amount is not deposited in the HSA on January 1. If you are a single subscriber, your employer will contribute $58.34 each month in your HSA as long as you remain eligible for enrollment in a consumer-directed health plan and health savings account. Members may also choose to make tax-free contributions to their own health savings accounts, up to IRS annual limits. Learn more about the Group Health HealthPays HSA (CDHP) plan rates and benefits or call Customer Service at HealthEquity, the trustee for your HSA, at 1-877-873-8823.

Can I invest the money in my HSA?
Yes, similar to an IRA, many HSAs let you choose to invest a portion of your account balance in stocks, bonds, mutual funds, CDs and/or other annuities. With your Group Health HeathPays HSA, you can invest in pre-selected mutual funds after you reach a $2,000 balance in your account.

Can I roll the money from my IRA into my HSA?
Yes, you can make a one-time rollover from your IRA into your HSA. You can't however roll money into your IRA from your HSA. Note that a rollover will count against annual contribution limits.

How much money can I contribute to my HSA?
In 2014, the maximum annual contribution limits set by the IRS for an individual account is $3,300 and the maximum contribution for family coverage is $6,550. People ages 55 and older may contribute up to $1,000 more annually in addition to the limits above.

What happens to my HSA if I leave my job or retire?
You may take that money with you wherever you go — it's your money and your account. If you're on Medicare or go to another employer that doesn't have a qualified CDHP, you can still use your HSA money to pay for co-pays and qualified medical expenses, but won't be able to make contributions to your HSA.

Does the money I have in my HSA rollover from year to year or do I lose that money at the end of the year?
The money rolls over from year to year. You don't lose the money left in your HSA or the interest it's earned.

Can I take the money out of my HSA any time I want?
Yes, you can take the money out anytime tax-free and without penalty as long as it's to pay for qualified medical expenses. If you take money out for other purposes, however, you'll have to pay income taxes on the withdrawal plus a 20 percent penalty.

If I get an HSA, but don't cover my children under that plan - can I still use the money in my HSA to pay for my children's medical expenses?
Yes, the money in your HSA can be used to pay for qualified medical expenses of any family member who qualifies as a dependent on your tax return. However, if the dependent isn't covered under your plan, his/her expenses won't be applied toward your deductible.

With a HSA plan, do I pay for the full doctor's office visit when I go to the doctor?
You're responsible to pay the amount your insurance has contracted to pay your doctor, typically a discounted rate, until your deductible is met. You can use your HSA for this expense. It's best to have your doctor's office put the charge through to your insurance so that you can receive credit toward your deductible and know exactly what to pay. Some doctors may require that you pay up front, but most bill your insurance and then bill you only once the claim has been processed.

Can I use the money in my HSA for non-medical expenses?
Yes, but if you do (and you are under age 65) you'll be taxed on the money you use and assessed a 20 percent penalty. Once you are 65, you'll be taxed for moneys used for nonmedical expenses, but won't pay the penalty.

Contacting Group Health


If I have more questions about Group Health Cooperative, who should I ask?
You may contact Group Health's Customer Service directly at 1-888-901-4636, Monday through Friday, between 8 a.m. and 5 p.m.

 

*OIC Provider Form A
**According to a study published in Health Affairs in May 2010

 

 

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