---

---

1. Who are our health care providers?

• Providers. Group Health Cooperative is the insurance provider, under the Group Health “Options” plan, providing medical and limited vision insurance. Dental insurance is provided by Washington Dental Service (WDS) (see end of these FAQs for more details on WDS).
• Deductible. The medical deductible is $1500 per person; the family rate is two times this rate or $3,000 maximum.  
• Out-of-pocket max. Under the medical plan, the annual out-of-pocket maximum (the maximum amount you pay out of pocket for medical services) is $5,100 per person, including the deductible; the family plan rate is two times that amount.
• Benefit coverage. The co-insurance level (the amount the insurance company pays) for providers “in network” with Group Health is 90%.The co-insurance level for providers “out of network” is 80%.
• Mental health benefits. Mental health benefits for both in-patient and out-patient services are unlimited.
• Preventive care. Preventive care co-insurance (the amount the insurance company pays) is 100% not subject to a co-pay or deductible.
• Prescription drugs. Prescription drug are subject to the deductible, then co-pays are a two-tier payment system  ($15 generic/$30 brand In-Network; and $30 generic/$60 brand Out-of-Network).
• Vision coverage. Limited vision coverage is provided for all medical plan enrollees, including all enrolled dependants. Coverage includes one annual vision exam, but does not include hardware.

2. How do I select a health care provider?
With the Group Health Options Plan, you may see any licensed health care provider.  Coverage will be determined by whether the provider is “in network,” a “participating provider,” or “out of network,” as follows: 

In network – 90% coverage.If your health care provider is contracted with Group Health (an “in network” provider), simply select them as your Primary Care Provider (PCP) by calling Group Health Customer Service once you are enrolled at 1-888-901-4636.  All provider charges will be paid at 90% after the deductible has been satisfied.

Participating provider – 80% coverage with no balance billing. If your provider is not contracted with Group Health but is contracted with First Choice Health Network (a “participating” provider), Group Health will pay 80% of provider charges after the deductible has been satisfied.  And there will be no “balance billing,” meaning that your doctor can’t charge you for the “balance” of her fees, above the cost she has contracted for with First Choice—so you truly pay only 20% for services.

Out of Network – 80% coverage with balance billing. If your current provider is not contracted with Group Health (an “out of network” provider), you may continue to see them. Group Health will pay 80% of provider charges after the deductible has been satisfied, but your doctor can balance bill you, meaning that your doctor can charge you for fees above the cost paid for by Group Health.

3.  How do I find out if my provider is contracted with either Group Health or First Choice Health Network?

To find Group Health “in network” providers, go to www.ghc.org/provider/index.jhtml. Click on the “Provider Directory Link.”  Select “Options” from the drop down box.  Enter in the name of the provider you are looking for under the “Search by provider name.”  

For “participating providers” with First Choice Health network, go to www.fchn.com.  Click on the “Click Here to Finda Doctor or Hospital” button in the upper left hand corner of the screen.  You may then search for a provider by name, specialty, or location. 

4.  Where can I see a more detailed benefits description of my health insurance plan? 

For a more detailed summary of the benefits you have under Group Health, click here.

5.  Does Group Health Cover Non-Formulary Medications?
Yes.  Prescription drug coverage is handled in one of two ways.  If your prescription is on the Group Health formulary and is dispensed from a Group Health contracted pharmacy (“in network”), you will pay either a $10 co-pay for generic drugs, or a $20 co-pay for brand name drugs. 

If your prescription is dispensed from a non-Group Health pharmacy (an “out of network” pharmacy), you will pay either a $15 co-pay for generic or a $25 co-pay for brand name drugs.  Dispensing of a generic drug is required unless a brand drug is medically necessary.

To receive the lowest co-pays, members should use a Group Health contracted pharmacy (“in network”) and receive formulary medications.

6.  Are there Group Health Contracted Community Pharmacies located in San Juan County?

Yes.  Friday Harbor Drug in Friday Harbor, Ray’s Pharmacy in Eastsound, and Lopez Island Pharmacy on Lopez Island are contracted with Group Health as “in network” providers.

7. Do I need a referral to see a specialist?

A referral is not necessary for outpatient services at the “out-of-network” benefit level.  Pre-authorization by your primary care physician is only needed for outpatient high-end radiology (such as an MRI) and scheduled inpatient hospitalization.  Payment for these services will be made at 80% of provider charges after the deductible has been satisfied.  If the specialist is contracted with First Choice Health Network, there will be no balance billing; if it is not, there can be balance billing.

To receive benefits at the 90% payment level, in many cases, you must have a referral from your Primary Care Provider (PCP) to see contracted specialists. 

8.   Are my enrolled dependents covered up to age 26?

Yes.  Under a recently-enacted law, enrolled dependents are covered up to age 26.This is true for any health insurance plan in the State of Washington, including the proposed new Group Health Options plan.

9.  Can I enroll my dependents on the dental plan?

Yes, you may enroll your dependents on your County dental insurance plan.  The County will pay for your own “self” enrollment, and you must pay 100% of the premium for your dependents. In other words, the County will pay 100% of the “self” rate for you, and you will pay the difference between the “self” rate and the dependent coverage option that you choose.

10.  With new dependents enrolled on the County dental plan, will our rates shoot up in 2011?

No.  Like car insurance, insurance rates rise with higher use, or higher “utilization.”  We have anticipated that with dependents newly added to the County’s group dental plan, there will be a spike in utilization during 2010.  We have, therefore, contracted with WDS for two years, during which the rates stay the same for both 2010 and 2011.  This ensures that even with higher utilization in 2010, the rates will not shoot up in 2011.  There are no guarantees for 2012.

11.  Who do I contact with further questions about the change in medical and dental plans?

You can contact CountyAdministration with questions:

Pamela Morais, pamelam@sanjuanco.com

You can also contact the County's health insurance brokers, Mark Rose or Christine Baldwin Resource Group, at 877-455-5640. Their website is: http://www.BaldwinRGI.com