The UNMC/UNO Benefits Office recently sent out a brief survey asking for feedback concerning what questions employees have on health and insurance benefits. (Annual NUFlex enrollment begins Oct. 26.)
To address these questions, the UNMC/UNO Benefits Office will be providing a series of articles this week to go over the most commonly asked questions. If you submitted a question that you do not see an answer for in this series, we encourage you to reach out to the benefits office directly via email.
Today’s question and answers will pertain to the medical coverage offered by the university.
Q: What is a deductible?
A: A deductible is the amount you will pay prior to the insurance company sharing the cost of medical expenses. The only exception to this would be preventative services.
Q: What are preventative services?
A: Preventative services consist of services that include check-ups and screenings to prevent illness, disease, and other health-related problems. This can also include vaccinations. Please reference this medical chart to review the preventative service applicable to each University medical plan.
Q: What is co-insurance?
A: Co-insurance is the cost-sharing percentage of covered health care services split between you and the insurance company once you have met your deductible. If you look at the medical chart provided, the first percentage listed is how much the insurance company pays and the second percentage is the employee and/or dependent’s responsibility.
Q: What is a Stop-Loss?
A: The Stop-Loss is how much an employee pays under the co-insurance on covered services before the insurance company picks up covered service expenses at 100%.
Q: What is the difference between the Preferred Tier, In-Network Tier, and Out-of-Network Tier for providers?
A: The Preferred Tier includes providers, such as Nebraska Medicine and Children’s Hospital, that are offering a discount on their services. The lower cost is reflected in the lower deductible, co-insurance and stop-loss. The in-network providers are providers that have contracts with UMR to provide services at a specific dollar amount. Out-of-network providers are providers who do not have a contract under the university plan. Out-of-network providers can charge over the negotiated rate that in-network providers can charge. This means that if a provider charges over what UMR’s contractual rate is for a service, the provider can bill the employee and/or dependent for the additional amount.
Q: Can you provide an example of how a bill gets processed under each tier?
A: This is an example using the Basic Option PPO Plan. The employee did not have any charges prior to this procedure: Cost of the procedure is $15,000.
- Preferred Tier Example – The employee would be responsible for the first $300 of this bill ($15,000-$300= $14,700). Then co-insurance would be applied at the 85%/15% rate, so you subtract the 85% that insurance will pay ($14,700-$12,495=$2,205). The balance is $2,205 at the 15% rate of co-insurance, however, the stop-loss for this tier is $1,450. You will only be responsible for the $1,450. The insurance company will pick up the remaining $755. They also will pay 100% of Preferred Tier covered services on the employee for the remainder of the calendar year. Total out of pocket expense for the employee is $1,750.
- In-Network Tier Example – The employee would be responsible for the first $450 of this bill ($15,000-$450= $14,550). Then co-insurance would be applied at the 70%/30% rate, so you would subtract the 70% that insurance will pay ($14,550-$10,185=$4,365). The balance is $4,365 at the 30% rate of co-insurance; however, the stop-loss for this tier is $1,600. You will only be responsible for the $1,600. The insurance company will pick up the remaining $2,765. They will also pay 100% of in-network covered services on the employee for the remainder of the calendar year. Total out-of-pocket expense for the employee is $2,050.
- Out-of-Network Tier Example – This provider, due to being out of network, charges $17,000 for the same procedure. The insurance company will only pay at the contractual rate set with In-Network Providers. The employee will be responsible for the first $650 of this bill ($15,000-$650=$14,350). Then co-insurance would be applied at the 55%/45% rate, so you would subtract the 55% that insurance will pay ($14,350-$7,892.50=$6,457.50). The balance is $6,457.50 at the 45% rate of co-insurance; however, the stop-loss for this tier is $2,000. You will be responsible for the $2,000. The insurance company will pick up the remaining $4,457.50. Remember that the additional $2,000 that the provider charged for this procedure over the insurance company’s contracted rate? You will also be billed that amount. The insurance company will pay 100% of out-of-network covered services at the contractual rate on the employee for the remainder of the calendar year. If there are additional charges over the contractual rate, the employee will be responsible for those charges. Total out of pocket expense for the employee is $4,650. As a reminder, if there are any other out-of-network charges during the calendar year, any amount of the contractual rate set with in-network providers will be the employee’s responsibility.
Q: Where can I find a list of Preferred Tier and/or In-Network Providers?
A: This can be found on the UMR website. You will need to create an account with UMR. To create an account please have your UMR insurance card available. Once you have an account, you can log in and on the right-hand side click on the “Find a provider” button. On the right-hand side, you will select the person on your plan you are wanting to find a provider for. Then in the middle section you will click the “View Providers” button. A separate screen will pop up with four links. The first link is for In-Network providers. The second link is for the Behavioral Health Directory. The third link is a list of National Contracted Vendors. Finally, the fourth link is the Enhanced Tier. The Enhanced Tier will list those who are in the Preferred Tier. To find a provider in the Enhanced Tier, click on the link, and a new screen will appear. On this screen you can set the parameters for your search by including a provider’s specialty and location. This same method will apply to the In-Network provider links as well.
Q: What is a Preferred Provider Organization (PPO) Plan?
A: A PPO is a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network.
Q: What is a High Deductible Health Plan (HDHP)?
A: A High Deductible Health Plan is a type of health insurance with higher deductibles and lower premiums.
Q: Are pre-existing conditions covered?
A: The university’s coverage does not have a pre-existing condition exclusion on the medical plans.
Q: How can I determine how much a procedure will cost?
A: If you go to the UMR website and log in, you will scroll down on the home page until you see the Health Cost Estimator. Click on this tile, then click the “Estimate your care” button. The cost estimator will allow you to choose your location and type of procedure.