Frequently Asked Questions
- Who decides which benefits are offered to members and what the premium rates will be to members?
- What do I need to know about enrolling in Medicare prior to enrolling in a PERS sponsored health plan?
- What if I am working past age 65 or I am covered under a spouse's employer sponsored group plan? Do I need to enroll in PERS when I become eligible for Medicare?
- What if my spouse and I are currently covered under a retiree plan and I will become Medicare eligible before my spouse? What are our coverage options through PERS?
- How do I pick a plan that 's right for me?
- What is the difference between indemnity plans and managed care plans?
- What is a PPO plan?
- May I change carriers at any time?
- How am I covered outside the country?
- What is the difference between individually purchased insurance and the PERS sponsored health insurance?
- Does PERS offer open enrollment?
- If I am retired from the Military and want to enroll with Tri-Care will I have to terminate my PERS coverage? Can I come back to PERS at a later date?
- How will I use the Non-Medicare PPO Plan to make sure I receive the best benefits?
- Why do health plan premium rates go up every year?
Who decides which benefits are offered to members and what the premium rates will be to members?
The PERS board reviews and approves the health plan contracts and benefits of the individual health plans. PERS strives to offer the best premiums possible while maintaining a high level of benefits for retirees.
What do I need to know about enrolling in Medicare prior to enrolling in a PERS sponsored health plan?
Please refer to pages 3 and 4 in the 2008 member handbook where there is information about your Medicare enrollment along with other helpful information. All Medicare eligible members and dependents are required to enroll in both Medicare Part A and Part B to be eligible for a PERS sponsored health plan. Enrollment into one of the PERS sponsored Medicare Plans will automatically enroll PERS members into Medicare Part D.
What if I am working past age 65 or I am covered under a spouse's employer sponsored group plan? Do I need to enroll in PERS when I become eligible for Medicare?
You and/or your spouse can enroll at anytime, even after age 65, as long as the prior coverage was employer sponsored and were covered at least 24 consecutive months just prior to enrolling in a PERS sponsored plan. If covered under Active employer sponsored group coverage, as an actively working employee, enrollment in Medicare Part B can be delayed because, most often, the employer coverage is primary over Medicare. There would be no need to pay the Part B premiums during this time. However, once the active group coverage ceases you and/or your spouse, if Medicare eligible, will need to contact the Social Security Administration approximately three months prior to when the active group coverage ends to ensure proper enrollment in Part B. All Medicare eligible members and dependents are required to have both Medicare Part A and Part B to be eligible for a PERS sponsored health plan.
What if my spouse and I are currently covered under a retiree plan and I will become Medicare eligible before my spouse? What are our coverage options through PERS?
You and/or your spouse can enroll at anytime, as long as the prior coverage was employer sponsored and you were covered at least 24 consecutive months just prior to enrolling in a PERS sponsored plan. Most public employers are required to offer their group plans to retirees and eligible dependents until they are Medicare eligible under Oregon Statute ORS 243.303. While PERS is available to the non-Medicare spouse, it may not be the best option. Usually it is best to leave your spouse enrolled in the retiree plan and you would enroll in PERS. The premiums and benefits for the spouse generally will be better through the retiree plan than through PERS. Then, when your spouse is eligible for Medicare you can enroll your spouse in PERS. If the reverse is true, if your spouse will be Medicare eligible before you, your spouse can enroll in PERS while you remain on the retiree plan until you become Medicare eligible. Becoming Medicare eligible is usually the last enrollment opportunity to enroll in PERS.
How do I pick a plan that 's right for me?
There are several questions you should ask yourself when selecting a plan. First, you need to determine the plans that are available in your area. Depending on where you live, you could have up to five different plans to choose from. You can find service area locations for all the plans in the current member handbook. Once you have determined the plans available to you, the next important thing to ask yourself is, "Do my physicians participate with the plans". You can obtain this information by contacting the health plan directly, or accessing their website. Also consider your travel habits and the plan's out of area benefits. Does the plan require you to obtain referrals to specialists? Do you like to pay a simple co-payment fixed amount that the member pays at the time of service. Generally the co-payment is the only cost the member will have for a particular service. at the time of service rather than receive billings? All of these can be important in choosing the right plan. The Medicare Plan Options grid will provide you with key features of the PERS sponsored health plans. Once you determine which plans provide the features that are important to you, review the benefit and rate comparisons in the current member handbook. This will assist you in determining which plan is right for you.
What is the difference between indemnity plans and managed care plans?
Indemnity type plans have no service areas and no contracted providers. Claims are paid on a fee-for-service basis. Managed care plans have specific service areas and contracted providers. You must select a primary care physician and often need pre-approval before obtaining specialist services.
What is a PPO plan?
PPO plans, as is true of indemnity plans, allow you to choose any physician you want. The PPO benefits are designed to save you money if you use providers who have signed "preferred" contracts. PPO plans do have specific service areas where providers are available, although they usually cover wider geographic regions than managed care plans.
May I change carriers at any time?
No, Only during the annual plan change period, or if you are moving out of your health plan's service area.
How am I covered outside the country?
Medicare Advantage Previously known as Medicare + Choice or Medicare Part C. plans cover urgent and emergency services outside their service area. The ODS Medicare Supplement offers limited worldwide coverage for any medical services. Contact your health plan for specific coverage. Kaiser Permanente Health Plans has a $1,000 travel benefit that can be used for medical services received outside their service area. Providence Health Plans also offers a similar $1,000 travel benefit.
What is the difference between individually purchased insurance and the PERS sponsored health insurance?
The individual market can vary greatly. There are many plans that now offer prescription drug coverage through Medicare Part D. These plans may have a limited formulary (list of covered drugs) and the covered drugs can change. There also may be an annual deductible Generally applied on a calendar year basis. This is the amount of money each year that members pay out of their own pocket before the benefit plan begins to pay. Usually expressed as a per person amount. and many of the individually marketed plans include the 'doughnut hole' gap in the coverage for prescription drugs. PERS offers a prescription drug benefit that covers from the first dollar and there is no gap in coverage. PERS offers an open formulary, and also covers some drugs that are not covered by Medicare Part D. Individually marketed Medigap plans may also be age-rated, meaning that the cost increases as you grow older, often quite dramatically. When enrolling into the PERS Medicare plans, retirees with eight (8) or more years of PERS service are eligible for $60.00 per month toward their health plan. The PERS board negotiates with contracted health plans to offer good benefits at the lowest possible cost to PERS members.
Does PERS offer open enrollment?
In 2006, PERS offered its first open enrollment in 11 years. There are no immediate plans to offer another open enrollment. Enrollment opportunities are limited to those described in the enrollments section of the current member handbook. All PERS members will be notified if there is an opportunity in the future. PERS does offer a plan change opportunity to current members annually.
If I am retired from the Military and want to enroll with Tri-Care will I have to terminate my PERS coverage? Can I come back to PERS at a later date?
- If you are enrolled in Tri-Care and a PERS plan (ODS Health Plans, Providence , Kaiser, or Clear Choice) you are not required to cancel your PERS-sponsored health plan. Tri-Care will pay secondary to any other insurance plan you may have.
- If you do drop your PERS health insurance plan, you may rejoin the PERS Health Insurance Program at a later date if you have not had a lapse in group insurance coverage. You must rejoin PERS immediately after you cancel your Tri-Care coverage. Tri-Care is an employer sponsored group insurance plan.
- You cannot be enrolled in two Medicare Part D plans at the same time or have other retiree coverage, including Tri-Care, that is receiving Medicare funding. If you terminate your Medicare Part D coverage directly through Medicare, this will disenroll you completely from the PERS Health Insurance Program, including your medical and optional dental coverage.
How will I use the Non-Medicare PPO Plan to make sure I receive the best benefits?
Call your health plan for a Preferred Provider List, or ask your physician if he/she is a Preferred Provider. Remember, this plan is available only to PERS members not enrolled in Medicare.
Why do health plan premium rates go up every year?
Health plan premium rates have several cost components, and consequently there are different reasons associated with the continuing increase in premium rates. The components of health plan premium rates are:
- The cost of the service provided (prescription drugs, physician office visit, laboratory tests, xrays or MRI)
For several years the cost of individual health care services has increased faster than general inflation or other services consumers purchase. The reason for this is due to the rapid advance of technology. There are new laboratory tests, new prescriptions drugs, new procedures, etc. The cost of developing this new technology is built into the cost of these services. - The frequency these services are used
The frequency of services has also increased, meaning that the incidence of cardiac surgery or joint replacements per thousand persons has increased dramatically. - The intensity or level of technology needed
The intensity of services has also increased. Intensity means that instead of an xray to diagnose back pain, physicians now order a CT scan or an MRI. These new tests cost much more than an xray that would have been ordered in the past. - Administration of the health plan (claims payment, medical management, regulatory reporting and compliance, and quality control).
Administration costs of the health plans refer to those services that are often unnoticed by health plan members. An increase in federal and state regulations requiring health plans to track and report quality measures and preventative services have increased health plan administration costs. There have also been requirements placed on health plans for patient information privacy that has led to significant investment in new technology to comply with the federal regulations.