- HMO vs. PPO-type indemnity plan.
- HMO ZIP code service areas.
- Choosing a health care provider.
- Case management.
- Medical and pharmacy claims.
- Coordination of benefits.
- More information about the health plans.
HMO vs. PPO-type indemnity plan
An HMO is a type of managed care plan regulated by the Oklahoma State Insurance Department. To be eligible to enroll in an HMO, an employee must live or work within that HMO’s ZIP code service area. When an employee enrolls in an HMO, they must designate a primary care physician to coordinate all health care needs.
A PPO-type indemnity plan is a traditional fee-for-service plan that gives the member the freedom to visit any licensed health care professional without a referral. Members are responsible for deductibles, copays and coinsurance, and a calendar year out-of-pocket maximum typically applies. Once the out-of-pocket maximum is met, the plan typically pays 100% of allowable fees for covered services for the rest of that plan year.
All health plans offered through EGID provide medical and prescription drug benefits. Benefits are subject to each plan’s rules and certain cost-sharing features such as copays, deductibles and coinsurance.
HMO ZIP code service areas
Employees must live or work within an HMO’s ZIP code service area to be eligible. Refer to the current HMO ZIP code lists in the Employee Benefit Options Guide.
Choosing a health care provider
If an HMO plan is selected, the employee must designate a PCP. If they do not designate a PCP, one is selected for them. The PCP is the first point of contact when seeking health care and is responsible for coordinating and authorizing all health care. Failure to obtain authorization from the PCP can result in the denial of claims. For information on an HMO’s benefits, providers or drug formulary, please contact the HMO directly.
If a PPO plan is selected, the employee should confirm their medical provider or facility participates in the PPO Provider Network. The most current list of network providers is available on the PPO plan’s website or by calling EGID Member Services. If the employee decides to use a non-network provider or facility, the employee’s out-of-pocket costs can be substantially higher.
Each plan issues ID cards to its members. Providers and facilities often require a copy of the employee’s plan ID card and driver’s license or photo ID when they receive services.
Case management provides personalized assistance and coordination of medical services to help maximize benefits and is available with all health plans offered through EGID. Case management is helpful in the following situations:
- Terminal illness.
- Pregnancy and preterm infants.
- Mental health and substance use disorder.
- Non-network emergencies.
Medical and pharmacy claims
All PPO health plans use central claims offices that process claims and track annual deductibles, out-of-pocket maximums and services that have plan limitations.
The medical claims administrator processes an electronic explanation of benefits for each claim. An EOB describes how benefits were applied, including, e.g., the amount billed by the provider, write-off amount, member copay, deductible and coinsurance, and total payment to the provider. Members can check claim status and view EOBs via the PPO plan’s website.
In the event of an urgent eligibility issue, such as when a new employee needs a prescription and their pharmacy rejects the claim for no coverage, please contact EGID Member Services for assistance.
To safeguard your employees’ private health information, limit your exposure to their claims information. All the health plans available through EGID have processes in place that allow an employee or adult dependent to authorize the release of their protected health information to another person.
Coordination of benefits
If an employee or their dependents have medical or pharmacy costs that are also covered by another group health plan, the insurance plans coordinate their payments so that the total benefits are not greater than the billed charges, benefits allowed or amount of member responsibility. This is known as coordination of benefits. When a health or dental plan needs information on a member’s or dependent’s other health coverage to process a claim, verification of other insurance coverage is needed. If the member fails to provide the requested information, the claim is delayed or denied for noncompliance.
An employee’s group insurance plan through their employer is always primary. If the employee is also covered as a dependent under a spouse’s plan, that plan is secondary to the employee’s plan.
Different guidelines apply to dependents covered under both parents. In the absence of a court order indicating the primary plan, the determination may be based on which parent’s birth month is earlier in the calendar year. For example, if one parent was born in February and the other in April, the plan of the parent born in February is primary. This guideline is commonly known in the insurance industry as the birthday rule.
In cases where the birthday rule cannot apply, the determination is based on a court order, custody or financial responsibility for the dependents.
When there are two group health plans:
- Medical claims must be filed with the primary plan first. Once that claim is processed, a claim can then be filed with the secondary plan. This secondary claim can be only for amounts not paid by the primary plan, such as deductibles, coinsurance or copays. An employee must follow the COB procedures of both plans to ensure claims are processed smoothly. Under no circumstances will both plans pay as primary.
- Most pharmacies are able to electronically file claims with both the primary and secondary insurance plans; however, some pharmacies cannot file a secondary claim electronically. In this case, a paper pharmacy claim must be filed with the secondary plan after the primary plan processes the claim.
If you have questions about coordination of benefits, contact the specific plan.
More information about the health plans
A current list of the available health plans and a comparison of benefits for each plan can be found in the Employee Benefit Options Guide. Contact each plan for more details. Refer to Vendor Contact Information for Insurance Coordinators.