2016 Plan Overview - Providence Health Plan

Transcription

INDIVIDUALS & FAMILIES
2016 Plan Overview
Your partner in health and wellness
Resources to keep you well
As you evaluate health insurance plans, consider one that not only pays for treatments when
you’re sick but works actively to help you feel better and live well. Providence Health Plan
offers coverage choices that help you manage your overall health as well as your costs.
• Choose from a broad
range of plan types
with different levels of
deductibles, coinsurance
and copayments.
Our networks range
from a local base of medical home providers
to nearly 1 million providers nationwide.
Everyone deserves better health.
• It’s our Mission to take care of
people in need, so we strive to
improve the quality of life for
those in the communities we
serve by donating vital health
care services.
• We’re a local, not-for-profit health plan that
understands the specific issues and challenges
of Oregonians.
We are good at what we do and
we're recognized by peers.
• For 10 years in a row, we've
been recognized by the
Portland Business Journal as
one of Oregon's most
admired companies.
• The National Committee for Quality Assurance has
awarded Providence Health Plan an accreditation
status of Commendable for its Oregon Commercial
PPO plans. This signifies Providence Health Plan’s
service and clinical quality meet or exceed NCQA's
rigorous requirements for consumer protection and
quality improvement.
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• Award-winning care managers who
provide education and support for chronic
conditions, such as asthma and diabetes
Experience and innovation mean
better care for you.
• Health and wellness classes to help you
manage stress, achieve a healthy weight,
begin a yoga practice and more
• We’re part of Providence
Health & Services, one of
the nation’s top 10
most-integrated health
care providers, serving the
Pacific Northwest for nearly
160 years.
• An award-winning newsletter packed
with health and wellness information
from Providence health experts
• Patients ranked Providence Health eXpress, our
on-demand Web-based health care service, 4.8
out of 5 stars for satisfaction.
• With innovative telemedicine, bundled care
packages (e.g., one price guaranteed for certain
procedures) and close coordination between our
hospitals and clinics, you get better care.
We’re easy to work with.
• Our friendly, local customer
service representatives answer
your calls quickly – 80 percent are
answered within 30 seconds.
• For the past four years,
97 percent of all claims
were processed within 30 days.
• Access to ProvRN for free health advice,
24/7, from a registered nurse
• Tobacco cessation programs to help
tobacco users quit for good
Why choose Providence?
You’ll find a plan and options
to fit your unique needs.
Our FitTogether™ wellness programs
and services include:
97%
• You can get online claims and benefits
information easily through myProvidence, a
one-stop resource that can help you better
understand and use your health plan benefits.
You get more for your health –
and your health care dollar.
Health-enhancing extras for better
fitness and more fun
As a Providence Health Plan member,
you can enjoy savings on:
• Exclusive recreation discounts
through LifeBalance for:
°° Popular local and national family attractions,
such as zoos and amusement parks
°° Hundreds of fitness facilities throughout Oregon
°° Discounted tickets to local events, savings
at hotels nationwide and more
• Board-certified LASIK vision correction or
custom LASIK through our partner, TruVision
• Hearing aids (up to 60 percent off)
through our partner, TruHearing
Tools to maintain and improve health
With myProvidence, our secure member portal
and complete source for health, wellness
and benefits information, you can:
• Get a baseline of your overall health
with a personal health assessment
• Improve your health with Wellness Central, an
integrated health and wellness hub that offers
a personalized dashboard, health trackers and
assessments, a library of health videos and
articles, meal plans and medication information
• Search the online directory to find in-network
providers, review your claims history and calculate
how much of your deductible you’ve met
• Manage your health costs with our treatment
cost calculator and online bill pay options
This booklet offers an overview of our individual and family plans and premiums, which are subject
to change every year. For more information about plan benefits and enrollment requirements,
limitations and exclusions, see the plan contract or contact our sales team or your insurance
producer. To view a benefit summary, go to ProvidenceHealthPlan.com/sbc2016.
• You’ll receive discounts on
massage therapy, fitness
classes, gym memberships,
LASIK and other extras.
Providence Health Plan Sales Department
• You can attend online
classes and seminars, many
of which are free or discounted for members.
ProvidenceHealthPlan.com
503-574-5000 or 800-988-0088 (TTY: 711)
Feb. 1, 2016 – Dec. 31, 2016: 8 a.m. to 8 p.m., Monday – Friday
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Your lifestyle, your plan
Where to buy plans
Choose a 2016 health plan that best fits your life and your health. You’ll find robust
Purchase the right Providence plan for you at ProvidenceHealthPlan.com, or ask a Providence
benefits and extensive provider choices, plans with different levels of annual deductibles,
representative or your insurance producer for help. Providence plans are also available through
and HSA-qualified plans that let you save tax-free dollars for future medical expenses.
the Federal Health Insurance Marketplace at HealthCare.gov.
Two plan types are centered on a unique care model called medical home, which lets
you choose a primary care clinic near you with a team to coordinate your care.
Alternative care options
You can see a naturopath or other alternative care
provider for covered benefits, including periodic
exams and well-baby care. These services are
covered at the same rate as they would be for a
primary care provider, as long as the alternative
care provider is licensed to perform the services.
Balance, HSA Qualified, Standard and Essential
plans are available throughout Oregon.
Balance 1000 Gold Balance 2000 Silver Balance 4000 Silver Balance 6800 Bronze Choice 1000 Gold
With the Balance, Choice and Connect plans,
chiropractic manipulation and acupuncture
are covered with a $25 copay when
you use an in-network provider.
Flexibility to change plans
Plans available directly
from Providence or
your producer
Metal tier
Choice 2000 Silver Choice 4000 Silver Choice 6800 Bronze
Choice plans are available in the counties
specified in the map below.
Connect 1000 Gold Connect 2000 Silver We get it. Life throws curve balls that can change
your circumstances. When you buy directly from
Providence, you can switch to a medical plan with
a lower premium once during the contract year.
Connect 4000 Silver Connect 6800 Bronze Providence Oregon Standard Gold Plan
Dental coverage for you and your family
You can add dental coverage to any Providence
medical plan you buy directly from Providence
Health Plan or through an insurance producer.
The Providence Progressive Dental plan gives you
access to more than 2,000 in-network dental
provider listings in Oregon and southwest Washington
and more than 280,000 in-network provider listings
nationwide. The dental plan provides comprehensive
benefits with coverage for preventive care, such as
X-rays and cleanings, as well as basic and major services,
such as extractions, crowns and dentures. This option
is not available if you purchase your Providence medical
plan in the Federal Health Insurance Marketplace.
There’s a Providence plan for you and your
family, no matter where you live in Oregon.
Your rate will be calculated according to
your age and the county you live in. See the
map on p. 23 to find your rate area.
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Providence Oregon Standard Silver Plan
Providence Oregon Standard Bronze Plan HSA Qualified
HSA Qualified 2800 Silver
Baker
Benton
Clackamas
Clatsop
Coos
Crook
Curry
Deschutes
Douglas
Hood River
Jackson
Josephine
Klamath
Lane
Lincoln
Linn
Malheur
Marion
Multnomah
Polk
Umatilla
Union
Wallowa
Washington
Yamhill
HSA Qualified 6000 Bronze Providence Essential (catastrophic)
Plans available from
the Federal Health
Insurance Marketplace
at HealthCare.gov
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Compare plans • Check rates • Apply and enroll online
Connect plans are available only in Clackamas,
Multnomah and Washington counties.
We can help you find the right plan for you. Apply and enroll:
• Online at ProvidenceHealthPlan.com
• Over the phone with a Providence representative
– Portland metro area 503-574-5000
– All other areas 800-988-0088
• With your insurance producer
Apply during open enrollment from Nov. 1, 2015, through Jan. 31, 2016. After the open enrollment period ends,
you must have a qualifying life event to enroll in a health insurance plan. Qualifying life events include losing employer
coverage, marriage and the birth of a child. See a list of qualifying life events at ProvidenceHealthPlan.com/qe.
5
Balance
Balance (continued)
After meeting your deductible,
you pay the following amounts for
covered services. The deductible is
waived for some covered services.
These are marked with ✓
Balance plans offer a balance of cost-saving features and
coverage for the services you use the most.
The plans include:
• Deductible waived for primary care, generic drugs,
and lab and X-ray services; your only out-of-pocket
expense for these is your copay, where applicable
Providence Signature Network: A network of
nearly 1 million health care providers nationwide,
both in Providence facilities and in other locations
Inpatient hospital services and maternity care
Emergency/Urgent Care
Emergency services
Urgent care services
Outpatient Diagnostic Services
• Coverage for routine vision services,
including glasses and contact lenses
X-ray and lab services
High-tech imaging services (such as PET,
CT, MRI)
Mental Health and Substance Abuse
• Provider choice, in or out of the
Providence Signature Network
• Pediatric dental coverage and optional
family dental coverage
• Deductible waived for covered services needed to
treat an accidental injury within 90 days of injury
A Balance plan may be right for you if access to
the widest range of providers is your top priority.
For a listing of our Signature Network providers,
visit ProvidenceHealthPlan.com/providerdirectory.
Accidental Injury Benefit
Preventive Care
Periodic health exams and well-baby
care (from any provider licensed to
perform the service)
Maternity prenatal care
Gynecological exams; Pap tests
Mammograms
6
Colorectal cancer screenings
(preventive age 50 and over)
Office Visits for Medical Services
Personal physician/provider
Specialist
Alternative care provider
Balance 1000
Gold
Balance 2000
Silver
Balance 4000
Silver
Balance 6800
Bronze
InOut-ofInOut-ofInOut-ofInOut-ofnetwork network network network network network network network
$1,000/ $2,000/ $2,000/ $4,000/ $4,000/ $8,000/ $6,800/ $13,600/
$2,000 $4,000 $4,000 $8,000 $8,000 $16,000 $13,600 $27,200
$4,000/ $8,000/ $6,850/ $13,700/ $6,850/ $13,700/ $6,850/ $13,700/
$8,000 $16,000 $13,700 $27,400 $13,700 $27,400 $13,700 $27,400
The deductible is waived for all covered services required to treat
an accidental injury within 90 days of injury.
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
$15 ✓
$40 ✓
$15 ✓
50%
50%
50%
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
$50 ✓
$90 ✓
$50 ✓
Balance 4000
Silver
Balance 6800
Bronze
Inpatient and residential services
Outpatient provider visits
Other Covered Services
Outpatient surgery at an ambulatory
surgery center or hospital-based facility
Chiropractic manipulation and
acupuncture (limited to three visits
combined per calendar year)
Prescription Drugs
20%
50%
30%
50%
50%
50%
50%
50%
50%
50%
50%
50%
30%
50%
50%
50%
$250 then $250 then $250 then $250 then $250 then $250 then $250 then $250 then
20%
20%
30%
30%
30%
30%
50%
50%
50%
50%
50%
50%
$75 ✓
$75 ✓
$75 ✓
$75 ✓
20% ✓
50%
30% ✓
50%
30% ✓
50%
50% ✓
50%
20%
50%
30%
50%
30%
50%
50%
50%
20%
50%
50%
30%
$25 ✓
50%
50%
50%
$25 ✓
50%
50%
30%
$15 ✓
$50 ✓
50%
50%
20%
50%
30%
50%
30%
50%
50%
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
Covered
Not
Covered
in full ✓ Covered in full ✓
Not
Generic
$15 ✓
$15 ✓
Covered
Not
Preferred brand name
$60 ✓
$45 ✓
Covered
Not
50%
Non-preferred brand name
50% ✓
Covered
Not
50%
Specialty and compound
50% ✓
Covered
Pediatric Vision Services (children up to age 19)
Routine eye exams (limited to one exam per Covered Covered Covered
calendar year)
in full ✓
✓
in full ✓
Vision hardware (frames, lenses, contact
Covered Covered Covered
lenses) - limits apply
in full ✓
✓
in full ✓
Adult Vision Services
Covered
Routine eye exams (limited to one
$30 ✓
$30 ✓
✓
exam per calendar year)
✓
✓
✓
Pediatric Dental Services* (children aged 18 years and younger)
Diagnostic and preventive services
Covered
Covered
(includes routine exams, cleanings,
30% ✓
in full ✓
bitewing X-rays, topical fluoride, space
in full ✓
maintainers)
Basic services (includes restorative fillings)
50%
70%
50%
Major services (includes crowns, dentures,
bridge work, oral surgery, endodontics,
50%
70%
50%
periodontics)
Preventive (ACA-required drugs only)
Balance
Annual deductible
Individual/Family
Annual out-of-pocket maximum
Individual/Family
Balance 2000
Silver
Hospital Services
• A deductible you can apply to the
out-of-pocket maximum
Balance 1000
Gold
* Dental services subject to medical deductible and out-of-pocket maximum
Not
Covered
Not
Covered
Not
Covered in full ✓ Covered in full ✓ Covered
Not
Not
Not
$50 ✓
$15 ✓
Covered
Covered
Covered
Not
Not
Not
$95 ✓
$60 ✓
Covered
Covered
Covered
Not
Not
Not
50%
50%
Covered
Covered
Covered
Not
Not
Not
50%
50%
Covered
Covered
Covered
Covered Covered Covered Covered Covered
✓
in full ✓
✓
in full ✓
✓
✓
in full ✓
✓
in full ✓
✓
Covered
Covered
Covered
$30 ✓
$30 ✓
✓
✓
✓
✓
✓
✓
✓
✓
30% ✓
Covered
in full ✓
30% ✓
Covered
in full ✓
30% ✓
70%
50%
70%
50%
70%
70%
50%
70%
50%
70%
7
Choice
Choice (continued)
Choice plans use a medical home model that provides a team of health professionals
dedicated to your overall well-being. Members select a medical home from the Providence
Choice Network. The medical home team then works to support all aspects of your
Providence Choice Network: A network of over 235
primary care clinics located throughout Oregon and
southwest Washington designated as medical homes
• More than 235 medical home clinics in
Oregon and southwest Washington that
provide patient-focused, coordinated care
• Access to specialists via referral from
the medical home in order to receive
coverage at the in-network level
• Separate deductibles and out-of-pocket
maximums in and out of the network
For a complete list of medical homes
and providers by location, visit
ProvidenceHealthPlan.com/providerdirectory.
A Choice plan might be right for you if you
value the convenience of a medical home and
a centralized team dedicated to your health.
Choice is best suited to members who live
within 30 miles of a Providence medical home.
Choice 1000
Gold
8
Mammograms
Choice 4000
Silver
Choice 6800
Bronze
$1,000/
$2,000
$4,000/
$8,000
Accidental injury benefit
Preventive Care
Choice 2000
Silver
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
$2,000/ $2,000/ $4,000/ $4,000/ $8,000/ $6,800/ $13,600/
$4,000 $4,000 $8,000 $8,000 $16,000 $13,600 $27,200
$8,000/ $6,850/ $13,700/ $6,850/ $13,700/ $6,850/ $13,700/
$16,000 $13,700 $27,400 $13,700 $27,400 $13,700 $27,400
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
Choice 4000
Silver
Choice 6800
Bronze
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
$15 ✓
$40 ✓
$15 ✓
50%
50%
50%
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
$50 ✓
$90 ✓
$50 ✓
50%
50%
50%
20%
50%
30%
50%
30%
50%
50%
50%
20%
20%
30%
30%
30%
30%
50%
50%
50%
50%
50%
50%
$75 ✓
$75 ✓
$75 ✓
$75 ✓
High tech imaging services (such as PET,
CT, MRI)
20% ✓
50%
30% ✓
50%
30% ✓
50%
50% ✓
50%
20%
50%
30%
50%
30%
50%
50%
50%
Prescription Drugs
20%
30%
$25 ✓
50%
50%
50%
$25 ✓
50%
50%
30%
$15 ✓
50%
50%
$50 ✓
50%
50%
20%
50%
30%
50%
30%
50%
50%
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
Not
covered
Not
covered
Not
covered
Not
covered
Not
covered
Covered
in full ✓
Not
covered
Not
covered
Not
covered
Not
covered
Not
covered
Covered
in full ✓
Not
covered
Not
covered
Not
covered
Not
covered
Not
covered
Not
Covered
covered in full ✓
Not
Generic
$15 ✓
$15 ✓
covered
Not
$60 ✓
$45 ✓
covered
Not
50%
50% ✓
covered
Not
50%
50% ✓
covered
Pediatric Vision Services (children aged 18 years and younger)
Routine eye exams (limited to one exam per Covered Covered Covered
calendar year)
in full ✓
✓
in full ✓
in full ✓
✓
in full ✓
Covered
$30 ✓
$30 ✓
✓
✓
✓
✓
Covered
Covered
30% ✓
in full ✓
in full ✓
maintainers)
50%
70%
50%
50%
70%
50%
periodontics)
Choice
Annual deductible
Individual/family
Individual/family
• Deductibles waived for doctor and specialist
visits, urgent care, lab and X-ray services,
chiropractic manipulation and acupuncture,
and generic and preferred brand-name drugs
Specialist
Hospital Services
Emergency services
• Adult vision coverage (exams and hardware)
Choice 2000
Silver
health, from wellness and prevention to active management of chronic conditions.
Choice plans offer:
Choice 1000
Gold
Covered
in full ✓
$15 ✓
$60 ✓
50%
50%
$50 ✓
$95 ✓
50%
50%
✓
in full ✓
✓
in full ✓
✓
✓
in full ✓
✓
in full ✓
✓
Covered
Covered
Covered
$30 ✓
$30 ✓
✓
✓
✓
✓
✓
✓
✓
✓
30% ✓
Covered
in full ✓
30% ✓
Covered
in full ✓
30% ✓
70%
50%
70%
50%
70%
70%
50%
70%
50%
70%
9
Connect
Connect (continued)
Connect plans combine a medical home model of care with a tailored provider
network to achieve substantial premium savings. You choose a medical home from
our Portland metro-area Providence Connect Network. The medical home model
Specialist
Hospital Services
medical home team members work collaboratively to support all aspects of your
health, from wellness and prevention to active management of chronic conditions.
Providence Connect Network: A Portlandarea network of over 65 primary care clinics
in Multnomah, Washington and Clackamas
counties designated as medical homes
• Some of the lowest premiums of any
Providence Individual & Family plans
Emergency services
Connect 4000
Silver
Connect 6800
Bronze
$15 ✓
$40 ✓
$15 ✓
50%
50%
50%
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
$25 ✓
$50 ✓
$25 ✓
50%
50%
50%
$50 ✓
$90 ✓
$50 ✓
50%
50%
50%
20%
50%
30%
50%
30%
50%
50%
50%
20%
20%
30%
30%
30%
30%
50%
50%
50%
50%
50%
50%
$75 ✓
$75 ✓
$75 ✓
$75 ✓
• More than 65 medical home clinics
in the Portland metro area
• Access to specialists via referral from
the medical home in order to receive
coverage at the in-network level
CT, MRI)
20% ✓
50%
30% ✓
50%
30% ✓
50%
50% ✓
50%
20%
50%
30%
50%
30%
50%
50%
50%
Prescription Drugs
20%
30%
$25 ✓
50%
50%
50%
$25 ✓
50%
50%
30%
$15 ✓
50%
50%
$50 ✓
50%
50%
20%
50%
30%
50%
30%
50%
50%
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
$25 ✓
50%
• A deductible that applies to the
• Deductible waived for doctor and specialist visits,
lab and X-ray services, and generic drugs
A Connect plan might be right for you if
convenience and cost savings are your
top priority, but you also value a medical
home team dedicated to your health.
For a complete list of medical homes
and providers by location, visit
ProvidenceHealthPlan.com/providerdirectory.
Annual deductible
Individual/family
Individual/family
Preventive Care
Mammograms
Connect 1000
Gold
Connect 2000
Silver
Connect 4000
Silver
Connect 6800
Bronze
$1,000/ $2,000/ $2,000/ $4,000/ $4,000/ $8,000/ $6,8000/ $13,600/
$2,000 $4,000 $4,000 $8,000 $8,000 $16,000 $13,600 $27,200
$4,000/ $8,000/ $6,850/ $13,700/ $6,850/ $13,700/ $6,850/ $13,700/
$8,000 $16,000 $13,700 $27,400 $13,700 $27,400 $13,700 $27,400
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Not
Covered
Not
Covered
Not
Covered
Not
covered in full ✓ covered in full ✓ covered in full ✓ covered
Not
Not
Not
Not
Generic
$50 ✓
$15 ✓
$15 ✓
$15 ✓
covered
covered
covered
covered
Not
Not
Not
Not
$95 ✓
$60 ✓
$60 ✓
$45 ✓
covered
covered
covered
covered
Not
Not
Not
Not
50%
50%
50%
50% ✓
covered
covered
covered
covered
Not
Not
Not
Not
50%
50%
50%
50% ✓
covered
covered
covered
covered
Routine eye exams (limited to one exam per Covered Covered Covered Covered Covered Covered Covered Covered
calendar year)
in full ✓
✓
in full ✓
✓
in full ✓
✓
in full ✓
✓
Covered Covered Covered Covered Covered Covered Covered Covered
in full ✓
✓
in full ✓
✓
in full ✓
✓
in full ✓
✓
Covered
Covered
Covered
Covered
$25 ✓
$25 ✓
$25 ✓
$25 ✓
✓
✓
✓
✓
Not
Not
Not
Not
Not
Not
Not
Not
covered covered covered covered covered covered covered covered
Covered
Covered
Covered
Covered
30% ✓
30% ✓
30% ✓
30% ✓
in full ✓
in full ✓
in full ✓
in full ✓
maintainers)
50%
70%
50%
70%
50%
70%
50%
70%
50%
70%
50%
70%
50%
70%
50%
70%
periodontics)
Connect
10
Connect 2000
Silver
provides a team of health professionals dedicated to your overall well-being. The
Connect plans offer:
Connect 1000
Gold
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
50%
50%
50%
50%
50%
Covered
in full ✓
11
Standard
Standard (continued)
Benefits for Standard plans are defined by the state of Oregon. Choose a Gold, Silver or Bronze
plan with deductibles ranging from $1,250 to $5,000. The Standard Bronze plan is HSA qualified.
Standard plans offer:
both in Providence facilities and in other locations.
• Copays starting as low as $20 and
deductibles as low as $1,250
Providence Oregon
Standard Gold
Providence Oregon
Standard Silver
Providence Oregon
Standard Bronze*
In-network
Out-ofnetwork
In-network
Out-ofnetwork
In-network
Out-ofnetwork
10%
50%
30%
50%
50%
50%
Hospital Services
Emergency services
10%
10%
30%
30%
50%
50%
$60 ✓
50%
$90 ✓
50%
$120
50%
10%
50%
30%
50%
50%
50%
• The option to add dental coverage with the
Providence Progressive Dental Plan, as long
as you buy a plan directly from Providence
Health Plan or through a producer
CT, MRI)
10%
50%
30%
50%
50%
50%
10%
50%
30%
50%
50%
50%
$20 ✓
50%
$35 ✓
50%
$60
50%
10%
50%
30%
50%
50%
50%
Not
covered
Not
covered
Not
covered
Not
covered
Not
covered
Not
covered
Covered in
full ✓
Not covered
Covered in
full ✓
Not
covered
Covered in
full ✓
Not
covered
$10 ✓
Not covered
$15 ✓
Not covered
$20
Not covered
$30 ✓
Not covered
$50 ✓
Not covered
$80
Not covered
50% ✓
Not covered
50% ✓
Not covered
50%
Not covered
Not covered
50% ✓
Routine eye exams (limited to one exam per Covered in
Covered ✓
calendar year)
full ✓
50% ✓
Not covered
50%
Not covered
Covered in
full ✓
Covered ✓
Covered in
full ✓
Covered ✓
Covered in
full ✓
Covered ✓
Covered in
full ✓
Covered ✓
A Standard plan might be right for you if you
want to minimize your health coverage costs
while receiving more streamlined benefits.
To note: Standard plans do not cover chiropractic
manipulation, acupuncture, adult routine vision exams
and vision hardware, or pediatric dental services.
Standard
Annual deductible
Individual/family
Individual/family
Preventive Care
Periodic health exams and well-baby care
(from any provider licensed to perform
the service)
Mammograms
acupuncture
Prescription Drugs
Generic
Providence Oregon
Standard Gold
Providence Oregon
Standard Bronze*
In-network
Out-ofnetwork
In-network
Out-ofnetwork
$2,500/
$5,000
$12,700/
$25,400
$2,500/
$5,000
$6,350/
$12,700
$5,000/
$10,000
$12,700/
$25,400
$5,000/
$10,000
$6,350/
$12,700
$10,000/
$20,000
$12,700/
$25,400
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
In-network
Out-ofnetwork
$1,250/
$2,500
$6,350/
$12,700
Covered in
full ✓
Covered in
full ✓
Covered in
full ✓
Covered in
full ✓
Providence Oregon
Standard Silver
50%
50%
50%
Covered in
full ✓
Covered in
full ✓
Covered in
full ✓
50%
50%
50%
Covered in
full ✓
Covered in
full ✓
Covered in
full ✓
50%
50%
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
$20 ✓
50%
$35 ✓
50%
$60
50%
Specialist
$40 ✓
50%
$70 ✓
50%
$100
50%
$40 ✓
50%
$70 ✓
50%
$100
50%
12
Covered in
full ✓
Covered ✓
Routine eye exams (limited to one exam per
Not covered Not covered Not covered Not covered Not covered Not covered
calendar year)
Pediatric Dental Services (children aged 18 years and younger)
maintainers)
periodontics)
* HSA Qualified
13
HSA Qualified
HSA Qualified (continued)
These high-deductible health plans have lower premiums. You get affordable coverage
and the flexibility to choose any provider. With an HSA Qualified plan, paired with
a tax-exempt health savings account, you save pre-tax dollars to pay for future
with unparalleled support to help you manage your account and use it wisely.
• Care from specialists without a referral
• Lower premiums with most services
subject to the deductible
In-network
Out-of-network
In-network
Out-of-network
20%
50%
20%
50%
Specialist
20%
50%
20%
50%
20%
50%
20%
50%
20%
50%
20%
50%
Hospital Services
• In-network preventive care and adult routine vision
services that are covered before the deductible
Emergency services
20%
20%
20%
20%
20%
50%
20%
50%
20%
50%
20%
50%
High-tech imaging services (such as PET, CT,
MRI)
20%
50%
20%
50%
20%
50%
20%
50%
20%
50%
20%
50%
• A preferred rate when you open a health
savings account with HealthEquity, a
partner of Providence Health Plan
Outpatient surgery at an ambulatory surgery
center or hospital-based facility
20%
50%
20%
50%
Not covered
Not covered
Not covered
Not covered
Covered in full ✓
Not covered
Covered in full ✓
Not covered
An HSA Qualified plan might be right for you
if you actively manage your health care and
would like to use pre-tax dollars to help do it.
Chiropractic manipulation and acupuncture
HSA Qualified
Annual deductible
Individual/family
Individual/family
Preventive Care
14
HSA Qualified 6000 Bronze
health care expenses. Providence HSA Qualified plans are easy to set up and come
HSA Qualified plans offer:
Prescription Drugs
Generic
20%
Not covered
20%
Not covered
20%
Not covered
20%
Not covered
20%
Not covered
20%
Not covered
Not covered
20%
Not covered
Covered ✓
Covered in full ✓
Covered ✓
Covered in full ✓
Covered ✓
Covered in full ✓
Covered ✓
$25 ✓
Covered ✓
$25 ✓
Covered ✓
Not covered
Not covered
Not covered
Not covered
30% ✓
Covered in full ✓
30% ✓
70%
50%
70%
70%
50%
70%
20%
Routine eye exams (limited to one exam per
Covered in full ✓
calendar year)
In-network
Out-of-network
In-network
Out-of-network
$2,800/$5,600
$5,600/$11,200
$6,000/$12,000
$12,000/$24,000
$5,000/$10,000
$10,000/$20,000
$6,450/$12,900
$12,900/$25,800
care (from any provider licensed to perform
the service)
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Mammograms
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Covered in full ✓
50%
Diagnostic and preventive services (includes
routine exams, cleanings, bitewing X-rays,
Covered in full ✓
topical fluoride, space maintainers)
50%
50%
periodontics)
15
Essential
Essential (continued)
After meeting your deductible, you pay
the following amounts for covered services.
The deductible is waived for some covered
services. These are marked with ✓
The Essential plan covers you in case of unforeseen major medical expenses.
This catastrophic plan is available only to individuals age 29 and younger.
The Essential plan offers:
• Affordable coverage with lower monthly premiums
In-network
Out-of-network
Covered in full
Covered in full
Hospital Services
• Coverage for up to three office visits per
calendar year before the deductible is met
Emergency services
Covered in full
Covered in full
• Prescription drug coverage
Covered in full
Covered in full
• The option to add family dental coverage
when you purchase a plan directly from
Providence Health Plan or a producer
Covered in full
Covered in full
High-tech imaging services (such as PET, CT, MRI)
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Not covered
Not covered
Covered in full ✓
Not covered
Generic
Covered in full
Not covered
The Essential plan might be right for you
if you are 29 or younger, don’t expect to
incur high medical expenses, want coverage
in case of a catastrophe and want to keep
your premium costs as low as possible.
To note: The Essential plan does not cover chiropractic
manipulation, acupuncture, adult routine vision exams
and vision hardware, or pediatric dental services.
Outpatient surgery at an ambulatory surgery center or
hospital-based facility
Chiropractic manipulation and acupuncture
Prescription Drugs
Essential
Annual deductible
Individual/family
Individual/family
Essential
Covered in full
Not covered
Covered in full
Not covered
Covered in full
Not covered
In-network
Out-of-network
Routine eye exams (limited to one exam
per calendar year)
Covered in full ✓
Covered ✓
$6,850/$13,700
$13,700/$27,400
Vision hardware (frames, lenses, contact lenses) - limits
apply
Covered in full ✓
Covered ✓
$6,850/$13,700
$13,700/$27,400
Routine eye exams (limited to one exam
per calendar year)
Not covered
Not covered
Not covered
Not covered
Preventive Care
Periodic health exams and well-baby care (from any
provider licensed to perform the service)
Covered in full ✓
Covered in full
Vision hardware (frames, lenses, contact lenses) - limits
apply
Covered in full ✓
Covered in full
Pediatric Dental Services (children aged 18 years and younger)
Covered in full ✓
Covered in full
Mammograms
Covered in full ✓
Covered in full
Diagnostic and preventive services (includes routine
exams, cleanings, bitewing X-rays, topical fluoride,
space maintainers)
Not covered
Not covered
Covered in full ✓
Covered in full
Not covered
Not covered
Major services (includes crowns, dentures, bridge work,
oral surgery, endodontics, periodontics)
Not covered
Not covered
16
Essential
50% first 3 visits ✓
Covered in full
Specialist
Covered in full
Covered in full
Covered in full
Covered in full
17
Compare our 2016 plans side-by-side
Plan name
Balance 1000
Gold
Balance 2000
Silver
Balance 4000
Silver
Balance 6800
Bronze
Choice 1000
Gold
Choice 2000
Silver
Choice 4000
Silver
Choice 6800
Bronze
Connect 1000
Gold
Connect 2000
Silver
Connect 4000
Silver
Metal level
Gold
Silver
Silver
Bronze
Gold
Silver
Silver
Bronze
Gold
Silver
Silver
Providence Health
Plan/Producer and/
or Marketplace
Providence Health
Plan/Producer and/
or Marketplace
Providence Health
Plan/Producer
Providence Health
Plan/Producer and/
or Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence Health
Plan/Producer
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence Health
Plan/Producer
Annual deductible
individual/family
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
$6,800/$13,600
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
$6,800/$13,600
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
individual/family
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
$6,850/$13,700
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
$6,850/$13,700
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
Where to buy
The deductible is waived for all covered services required
to treat an accidental injury within 90 days of injury
The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury
PPP office visit
$15 ✓
$25 ✓
$25 ✓
$50 ✓
$15 ✓
$25 ✓
$25 ✓
$50 ✓
$15 ✓
$25 ✓
$25 ✓
Specialist office visit
$40 ✓
$50 ✓
$50 ✓
$90 ✓
$40 ✓
$50 ✓
$50 ✓
$90 ✓
$40 ✓
$50 ✓
$50 ✓
Outpatient diagnostic lab and X-ray
20% ✓
30% ✓
30% ✓
50% ✓
20% ✓
30% ✓
30% ✓
50% ✓
20% ✓
30% ✓
30% ✓
Chiropractic manipulation
and acupuncture**
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
$25 ✓
Prescription drugs (generic)
$15 ✓
$15 ✓
$15 ✓
$50 ✓
$15 ✓
$15 ✓
$15 ✓
$50 ✓
$15 ✓
$15 ✓
$15 ✓
Preferred brand name drugs
$45 ✓
$60 ✓
$60 ✓
$95 ✓
$45 ✓
$60 ✓
$60 ✓
$95 ✓
$45 ✓
$60 ✓
$60 ✓
Inpatient hospital
20%
30%
30%
50%
20%
30%
30%
50%
20%
30%
30%
$250 then 20%
$250 then 30%
$250 then 30%
$250 then 50%
$250 then 20%
$250 then 30%
$250 then 30%
$250 then 50%
$250 then 20%
$250 then 30%
$250 then 30%
Urgent care visits
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
$75 ✓
Mental health - outpatient visits
$15 ✓
$25 ✓
$25 ✓
$50 ✓
$15 ✓
$25 ✓
$25 ✓
$50 ✓
$15 ✓
$25 ✓
$25 ✓
Adult vision exams
$30 ✓
$30 ✓
$30 ✓
$30 ✓
$30 ✓
$30 ✓
$30 ✓
$30 ✓
$25 ✓
$25 ✓
$25 ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered in full ✓
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Emergency services
Pediatric vision (exams and hardware)
Pediatric dental
Premium examples for non-tobacco users for rating Region A
Single, 26 years old
$263
$227
$207
$187
$249
$214
$195
$177
$223
$192
$175
Single, 55 years old
$573
$494
$450
$408
$541
$465
$424
$385
$486
$419
$382
Family: parents aged 38 and 40,
children aged 7 and 10
$975
$841
$766
$694
$920
$791
$722
$655
$829
$712
$651
Networks
Signature Network
Choice Network
Connect Network
A network of nearly 1 million health care providers nationwide,
A network of over 235 primary care clinics located throughout
Oregon and Southwest Washington designated as medical homes
A Portland-area network of over 65 primary care clinics
in Clackamas, Multnomah, and Washington counties
designated as medical homes
✓ Deductible waived for these services
* Coverage for 2 children only
** L imited to 3 visits combined
per calendar year
PLEASE NOTE: Benefit examples shown
above for in-network coverage only
18
For the full listing of in- and
out-of-network benefits, visit
19
Connect 6800
Bronze
Providence
Oregon
Standard Gold
Plan
Providence
Oregon
Standard
Silver Plan
Providence
Oregon
Standard
Bronze Plan
HSA Qualified
2800 Silver
HSA Qualified
6000 Bronze
Providence
Essential
Bronze
Gold
Silver
Bronze
Silver
Bronze
Catastrophic
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer and/or
Marketplace
Providence
Health Plan/
Producer
Providence
Health Plan/
Producer
Providence
Health Plan/
Producer and/or
Marketplace
$6,800/$13,600
$1,250/$2,500
$2,500/$5,000
$5,000/$10,000
$2,800/$5,600
$6,000/$12,000
$6,850/$13,700
$6,850/$13,700
$6,350/$12,700
$6,350/$12,700
$6,350/$12,700
$5,000/$10,000
$6,450/$12,900
$6,850/$13,700
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
$50 ✓
$20 ✓
$35 ✓
$60
20%
20%
$90 ✓
$40 ✓
$70 ✓
$100
20%
20%
50% first 3 visits
✓
Covered in full
50% ✓
10%
30%
50%
20%
20%
Covered in full
$25 ✓
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
$50 ✓
$10 ✓
$15 ✓
$20
20%
20%
Covered in full
$95 ✓
$30 ✓
$50 ✓
$80
20%
20%
Covered in full
50%
10%
30%
50%
20%
20%
Covered in full
$250 then 50%
10%
30%
50%
20%
20%
Covered in full
20%
20%
Covered in full
Providence Progressive Dental Plan option
Providence Progressive Dental provides comprehensive benefits that promote good
$75 ✓
$60 ✓
$90 ✓
$120
$50 ✓
$20 ✓
$35 ✓
$60
20%
20%
Covered in full
$25 ✓
Not covered
Not covered
Not covered
$25 ✓
$25 ✓
Not covered
health with coverage for preventive care, such as X-rays and cleanings. Basic and
major services, including extractions, crowns and dentures, are also covered. Through
the plan, you have access to more than 2,000 in-network dental provider listings in
Oregon and southwest Washington and more than 280,000 in-network provider listings
nationwide. To search for a dentist, visit ProvidenceHealthPlan.com/providerdirectory.
Providence Progressive Dental Plan features:
• No waiting periods for dental coverage
• In-network diagnostic and preventive care
services, such as exams, cleanings and X-rays,
are covered in full. You are also covered
for more extensive services, including root
canals, crowns, bridges and dentures.
• Progressive benefits reward proper dental care by
reducing your costs in subsequent years of service.
• You may be treated by any licensed dentist,
but your out-of-pocket costs will be lower
if you use an in-network provider.
• Rate: $32 per member per month
Providence Progressive Dental Plan
In-network
yr1
Network
yr2
Out-of-network
yr3
yr1
Providence
yr2
yr3
All other providers
Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓
Covered
Not covered
Not covered
Not covered
Covered
Covered
Not covered
$159
$256
$219
$173
$207
$164
$141
$346
$557
$476
$377
$451
$357
N/A
$589
$948
$811
$641
$766
$608
$176*
Deductible
$25
$25
Annual Maximum
Signature Network
A network of nearly 1 million health care providers nationwide,
$50
$50
$50
$1000
Waiting period
Diagnostic and preventive services (includes routine
exams, cleanings, bitewing X-rays, topical fluoride
(age 16 and younger), space maintainers)
$25
None
None
Covered
in full ✓
Covered
in full ✓
Covered
in full ✓
10% ✓
10% ✓
10% ✓
50%
40%
20%
70%
50%
30%
Major services (includes crowns, dentures, bridge
work, oral surgery, endodontics, periodontics)
75%
65%
50%
90%
80%
60%
You must purchase a PHP medical plan in order to purchase the Providence Progressive Dental Plan. Not available
when purchasing a Providence medical plan through the Federal Health Insurance Marketplace.
20
21
Glossary of Terms
Accidental injury
Marketplace
An injury that is due directly to an unintentional act,
independent of all other causes.
Also called an “exchange,” a health insurance
marketplace is a place where you can buy health
coverage online. If you qualify for a tax credit or subsidy
to help pay for your coverage, you must buy your health
plan through the Federal Health Insurance Marketplace,
located at HealthCare.gov.
Calendar year
The period from Jan. 1 through Dec. 31 each year
Coinsurance
A percentage of the amount you are responsible to pay a
health care provider for a covered service. For example, if
a health care service is covered at a 20 percent
coinsurance, you would pay 20 percent of the covered
costs, and the plan would pay 80 percent.
Copay
A fixed dollar amount that you are responsible for paying
to a health care provider at the time you receive the
service. For example, if an office visit is covered at a $20
copay, you would pay $20, and the plan would pay the
remaining covered costs.
Deductible
The amount you must pay for services that are covered
by the health plan before your plan will begin to pay for
these services. A new deductible must be met each
calendar year.
Dependent
A policyholder or eligible spouse or dependent who is
properly enrolled in the plan
Nonparticipating provider
A health care provider or facility with no agreement to
participate with Providence Health Plan. When you use
nonparticipating providers, you receive out-of-network
benefits and pay a higher coinsurance for your share of
the costs.
Out-of-pocket maximum
The total amount you will pay in deductible, copays and
coinsurance for covered services in a calendar year. After
you meet your plan’s out-of-pocket maximum, the plan
will pay for 100 percent of covered services for the
remainder of the year.
Effective date of coverage means the date upon
which coverage begins.
Exclusion
A service or supply not covered by the health plan
A participating provider who has agreed to provide or
coordinate medical care and is listed in the personal
physician/provider section of the Provider Directory
Exclusion period
Premium
A period of time during which all specified treatments or
procedures are excluded from coverage. If treatment was
covered under a previous plan, then the exclusion period
is reduced by each day of continuous prior creditable
coverage.
The monthly rate you pay for health plan coverage
Coverage is limited by quantity, frequency, provider
or type of service.
• Your age
• Whether or not you use tobacco
• The county where you live
Providence has combined Oregon
counties into three groups:
Group A:
Clackamas, Multnomah, Washington, Yamhill
Group B:
Benton, Douglas, Jackson, Josephine, Lane, Linn,
Marion, Polk
To determine the premium for yourself as an individual,
go to the rate sheet for the county in which you live,
use your age and choose the plan that fits your needs.
To determine the premium for you and your family,
go to the rate sheet for the county in which you
live, choose the plan that fits your needs, then
use the ages for each person to be covered. Add
the premium amounts for each family member to
determine your total. If you’re covering more than
three children 19 years of age and younger, only
add the premiums for your first three children.
PLEASE NOTE: Tobacco use is defined as the use of
tobacco products in any form for an average of four or
more times per week within the past six months.
Group C:
Baker, Clatsop, Columbia, Coos, Crook, Curry,
Deschutes, Gilliam, Grant, Harney, Hood River,
Jefferson, Klamath, Lake, Lincoln, Malheur,
Morrow, Sherman, Tillamook, Umatilla, Union,
Wallowa, Wasco, Wheeler
Participating provider
Effective date of coverage
Limitations
Several factors make up your monthly premium rate:
Member
A health care provider or facility with an agreement to
participate with Providence Health Plan. When you use
participating providers, you receive in-network benefits
and have lower costs.
The policyholder's spouse or eligible family member
22
Individual and Family plan rates for 2016
Provider network
A provider network is a collection of providers, hospitals
and facilities that have agreed to set reimbursement rates
for health care services delivered to members of a health
insurance plan. Providence Health Plan has three
networks that are matched to our various plans.
Service area
The geographic area in Oregon where the policyholder,
spouse of the policyholder or child-only member must
physically reside in order to qualify for coverage. Plan
availability may vary by county.
23
Individual and Family Plan Rates, Group A: Non-tobacco user
Group A counties: Clackamas, Multnomah, Washington, Yamhill**
** Connect plans are not available for purchase in Yamhill county.
Purchase these plans directly from Providence at ProvidenceHealthPlan.com or your insurance producer.
Plans marked * may also be purchased through the Federal Health Insurance Marketplace at HealthCare.gov.
Effective Jan. 1, 2016 – Dec. 31, 2016
Plan Name
Balance 1000 Gold*
Balance 2000 Silver*
Balance 4000 Silver
Balance 6800 Bronze*
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 2000 Silver*
Connect 4000 Silver
Connect 6800 Bronze*
Providence Oregon Standard Gold Plan*
Providence Oregon Standard Silver Plan*
Providence Oregon Standard Bronze Plan*
Providence Essential*
Age
Age
0 to 20
21
22
23
24
25
26
27
28
29
30
31
32
33
163
141
128
116
154
132
121
110
139
119
109
99
159
136
107
128
102
88
257
221
202
183
243
209
190
173
218
188
171
155
250
213
169
202
160
138
257
221
202
183
243
209
190
173
218
188
171
155
250
213
169
202
160
138
257
221
202
183
243
209
190
173
218
188
171
155
250
213
169
202
160
138
257
221
202
183
243
209
190
173
218
188
171
155
250
213
169
202
160
138
258
222
203
184
244
209
191
173
219
189
172
156
251
214
170
203
161
139
263
227
207
187
249
214
195
177
223
192
175
159
256
219
173
207
164
141
269
232
212
192
254
219
199
181
229
197
180
163
262
224
177
212
168
145
280
241
219
199
264
227
206
188
237
204
186
169
272
232
184
220
174
150
288
248
226
205
272
233
213
193
244
210
192
174
280
239
189
226
179
155
292
251
229
208
275
237
216
196
248
213
195
176
284
242
192
229
182
298
257
234
212
281
242
220
200
253
218
199
180
290
247
196
234
186
304
262
239
217
287
247
225
204
258
222
203
184
296
252
200
239
189
308
265
242
219
291
250
228
207
261
225
205
186
299
256
203
242
192
34
38
39
40
41
42
312
314
316
318
320
269
270
272
274
276
245
247
248
250
252
222
224
225
227
228
295
297
299
300
302
253
255
257
258
260
231
232
234
235
237
209
211
212
214
215
265
267
268
270
272
228
230
231
233
234
208
209
211
212
214
188
190
191
192
193
303
305
307
309
311
259
261
263
264
266
205
207
208
209
211
245
247
249
250
252
194
196
197
198
199
Not available to people age 30 and older
325
279
255
231
306
263
240
218
275
237
216
196
315
269
213
255
202
329
283
258
234
310
267
243
220
279
240
219
198
319
273
216
258
205
335
288
263
238
316
272
247
225
284
245
223
202
325
278
220
263
208
341
293
267
243
322
276
252
229
289
249
227
206
331
283
224
268
212
61
62
63
64
65
and
Over
723
622
567
514
682
586
534
485
613
528
482
436
702
600
475
568
450
739
636
580
526
697
599
546
496
627
540
492
446
718
613
486
581
460
759
653
596
540
716
616
561
509
644
554
506
458
738
630
499
597
473
771
663
606
549
729
627
570
519
654
564
513
465
750
639
507
606
480
771
663
606
549
729
627
570
519
654
564
513
465
750
639
507
606
480
Age
Plan Name
24
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
44
349
300
274
248
329
283
258
234
296
255
233
211
339
290
229
274
217
359
309
282
256
339
291
265
241
305
262
239
217
349
298
236
282
224
45
46
35
36
37
Age
47
48
371
386
402
420
320
332
346
362
291
303
315
330
264
275
286
299
350
364
379
397
301
313
326
341
274
285
297
311
249
259
270
282
315
327
341
357
271
282
294
307
247
257
268
280
224
233
243
254
361
375
391
409
308
320
334
349
244
254
264
276
292
303
316
330
231
240
250
262
49
50
51
52
53
54
55
439
378
344
312
414
356
324
294
372
320
292
265
426
364
289
345
273
459
395
361
327
433
373
339
308
390
335
306
277
446
381
302
361
286
480
413
376
341
453
389
354
322
407
350
320
289
466
398
315
377
299
502
432
394
357
474
407
371
337
426
367
335
303
488
417
330
395
312
525
452
412
373
495
426
388
352
445
383
350
317
510
435
345
412
327
549
473
431
391
518
445
406
368
466
401
366
331
534
456
361
432
342
573
494
450
408
541
465
424
385
486
419
382
346
557
476
377
451
357
56
57
58
59
60
600
627
655
669
698
516
539
564
576
601
471
492
514
525
548
427
446
466
476
497
566
591
618
632
659
487
508
532
543
566
443
463
484
494
516
403
420
440
449
468
509
532
556
568
592
438
458
479
489
510
400
418
437
446
465
362
378
396
404
421
583
609
637
651
678
498
520
544
556
579
395
412
431
440
459
472
493
515
526
549
373
390
408
417
434
25
Individual and Family Plan Rates, Group A: Tobacco user
Group A counties: Clackamas, Multnomah, Washington, Yamhill**
** Connect plans are not available for purchase in Yamhill county.
Plan Name
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
Age
Age
0 to 20
21
22
23
24
25
26
27
28
29
30
31
32
33
163
141
128
116
154
132
121
110
139
119
109
99
159
136
107
128
102
88
283
243
222
201
267
229
209
190
240
207
189
171
275
235
186
222
176
152
283
243
222
201
267
229
209
190
240
207
189
171
275
235
186
222
176
152
283
243
222
201
267
229
209
190
240
207
189
171
275
235
186
222
176
152
283
243
222
201
267
229
209
190
240
207
189
171
275
235
186
222
176
152
284
244
223
202
268
230
210
191
241
207
189
171
276
236
187
223
177
152
290
249
227
206
273
235
214
194
246
212
193
175
282
240
190
228
180
156
296
255
233
211
280
240
219
199
251
217
198
179
288
246
195
233
185
159
307
265
241
219
290
249
227
206
261
225
205
186
299
255
202
242
191
165
317
272
248
225
299
257
234
212
269
231
211
191
308
263
208
249
197
170
321
276
252
229
303
260
237
215
272
234
214
194
312
266
211
252
200
328
282
257
233
309
266
242
220
278
239
218
198
319
272
216
258
204
335
288
263
238
316
271
247
225
284
244
223
202
325
278
220
263
208
339
292
266
241
320
275
250
227
287
248
226
205
329
281
223
266
211
34
38
39
40
41
42
343
346
348
350
352
296
298
299
301
303
270
271
273
275
277
244
246
248
249
251
324
326
328
331
333
279
280
282
284
286
254
255
257
259
260
230
232
233
235
236
291
293
295
297
299
251
252
254
256
257
229
230
232
233
235
207
209
210
211
213
334
336
338
340
343
285
287
289
291
293
226
227
229
230
232
270
272
273
275
277
214
215
217
218
219
357
307
280
254
337
290
264
240
303
261
238
215
347
296
235
281
222
362
311
284
257
341
293
267
243
307
264
241
218
351
300
238
284
225
368
317
289
262
348
299
272
247
312
269
245
222
358
306
242
290
229
375
323
294
267
354
304
277
251
318
274
250
226
364
311
246
295
233
Age
Plan Name
26
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
44
384
330
301
273
362
311
284
258
326
280
256
232
373
319
252
302
239
395
340
310
281
373
321
292
265
335
289
263
239
384
328
260
311
246
45
46
35
36
37
Age
47
48
408
424
442
462
352
365
381
398
321
333
347
363
291
302
315
329
386
400
417
436
331
344
359
375
302
313
327
342
274
285
297
310
346
360
375
392
298
310
323
338
272
283
295
308
247
256
267
279
397
412
430
450
339
352
367
384
269
279
291
304
321
334
348
364
254
264
275
288
49
50
51
52
53
54
55
483
415
379
343
455
391
356
324
409
352
322
291
469
401
317
379
300
505
435
397
360
477
410
373
339
429
369
337
305
491
419
332
397
315
528
454
414
376
498
428
390
354
448
385
352
318
513
438
347
415
328
552
475
433
393
521
448
408
370
468
403
368
333
537
458
363
434
344
577
497
453
411
545
468
426
387
490
421
385
348
561
479
379
454
359
604
520
474
430
570
490
446
405
512
441
402
365
587
501
397
475
376
631
543
495
449
595
512
466
423
535
461
420
381
613
524
415
496
393
Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.
60
61
62
63
64
65
and
Over
660
689
721
736
768
568
593
620
634
661
518
541
566
578
603
470
491
513
524
546
623
651
680
695
725
535
559
585
597
623
487
509
532
544
567
443
463
484
494
515
560
585
611
625
651
482
503
526
538
561
440
459
480
491
512
398
416
435
444
463
641
670
701
716
746
548
572
598
611
637
434
453
474
484
505
519
542
567
579
603
411
429
449
458
478
795
684
624
566
750
645
587
533
674
581
530
480
773
660
523
625
495
813
700
638
578
767
659
600
545
689
594
542
491
790
674
534
639
506
835
719
655
594
788
677
617
560
708
610
557
504
812
693
549
656
520
849
729
666
603
801
687
627
570
720
621
567
513
825
705
558
666
528
849
729
666
603
801
687
627
570
720
621
567
513
825
705
558
666
528
56
57
58
59
27
Individual and Family Plan Rates, Group B: Non-tobacco user
Group B counties: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk
Plan Name
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
Age
0 to 20
167
143
131
119
157
135
123
112
162
138
110
131
104
89
21
22
23
Age
24
25
26
27
28
29
30
31
32
262
262
262
262
263
269
226
226
226
226
227
231
206
206
206
206
207
211
187
187
187
187
187
191
248
248
248
248
249
253
213
213
213
213
214
218
194
194
194
194
195
198
176
176
176
176
177
180
Connect plans are not available in these counties
255
255
255
255
256
261
218
218
218
218
219
223
172
172
172
172
173
177
206
206
206
206
207
211
163
163
163
163
164
167
141
141
141
141
141
144
275
237
216
196
259
223
203
184
285
245
224
203
269
231
211
191
294
253
230
209
277
238
217
197
298
256
234
212
281
241
220
200
304
262
239
216
287
247
225
204
310
267
244
221
293
252
229
208
267
228
181
216
171
148
277
237
187
224
177
153
285
244
193
231
183
158
289
247
196
234
185
295
252
200
239
189
302
258
204
244
193
33
34
38
39
40
41
42
314
318
321
323
325
327
270
274
276
278
280
281
247
250
252
253
255
257
224
227
228
230
231
233
297
301
303
304
306
308
255
258
260
262
263
265
232
235
237
238
240
241
211
214
215
216
218
219
305
310
312
314
316
318
261
264
266
268
269
271
207
209
211
212
214
215
247
250
252
254
255
257
196
198
200
201
202
203
331
285
260
236
312
269
245
222
335
289
263
239
316
272
248
225
342
294
268
243
322
277
252
229
348
299
273
247
328
282
257
233
322
275
218
260
206
326
278
220
264
209
332
283
225
268
213
338
288
229
273
216
61
62
63
64
65
and
Over
737
634
579
525
696
598
544
495
754
649
592
536
711
611
557
506
774
666
608
551
731
628
572
519
786
678
618
561
744
639
582
528
786
678
618
561
744
639
582
528
716
612
485
579
459
732
625
496
592
469
753
643
509
609
482
765
654
516
618
489
765
654
516
618
489
Age
Plan Name
28
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
356
306
279
253
336
289
263
239
346
295
234
280
222
44
45
46
35
36
37
Age
47
48
49
366
379
393
410
429
447
315
326
339
353
369
385
288
297
309
322
337
351
261
270
280
292
305
319
346
357
371
387
405
422
297
307
319
333
348
363
271
280
291
303
317
331
246
254
264
275
288
300
356
368
382
398
417
435
304
314
327
340
356
371
241
249
259
270
282
294
288
298
309
322
337
352
228
236
245
255
267
279
50
51
52
53
54
55
468
403
368
333
442
380
346
314
489
421
384
348
462
397
361
328
512
441
402
364
483
415
378
344
535
461
420
381
505
434
395
359
560
482
440
399
529
454
414
376
585
503
459
416
552
474
432
392
455
389
308
368
292
475
406
322
385
305
498
425
337
402
319
520
444
352
421
333
544
465
368
440
349
569
485
385
460
364
56
57
58
59
60
612
639
668
683
712
527
550
575
588
613
480
502
525
536
559
436
455
476
486
507
578
603
631
644
672
496
519
542
554
577
452
472
494
504
526
411
429
448
458
478
595
621
650
664
692
508
531
555
567
591
402
420
440
449
468
481
502
525
537
560
381
398
416
425
443
29
Individual and Family Plan Rates, Group B: Tobacco user
Group B counties: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk
Plan Name
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
Age
0 to 20
167
143
131
119
157
135
123
112
162
138
110
131
104
89
21
22
23
Age
24
25
26
27
28
29
30
31
32
289
289
289
289
290
295
248
248
248
248
249
254
226
226
226
226
227
232
205
205
205
205
206
210
272
272
272
272
273
279
234
234
234
234
235
240
213
213
213
213
214
218
194
194
194
194
194
198
280
280
280
280
282
287
239
239
239
239
240
245
190
190
190
190
191
194
227
227
227
227
228
232
180
180
180
180
180
184
155
155
155
155
156
159
302
260
237
215
285
245
223
203
314
270
246
223
296
254
232
210
323
278
253
230
305
262
238
217
327
282
257
233
309
266
242
220
334
288
262
238
316
271
247
224
341
294
268
243
322
277
252
229
294
251
199
238
188
162
305
260
206
247
195
168
314
268
212
254
201
173
318
272
215
257
204
325
278
220
263
208
332
283
224
268
212
33
34
38
39
40
41
42
346
350
353
355
357
359
298
302
303
305
307
309
271
275
277
279
280
282
246
249
251
253
254
256
326
331
333
335
337
339
280
284
286
288
290
292
255
259
260
262
264
266
232
235
237
238
240
241
336
340
343
345
347
349
287
291
293
295
296
298
227
230
232
233
235
236
272
275
277
279
281
283
215
218
219
221
222
224
364
313
286
259
344
295
269
244
369
317
289
262
348
299
272
247
376
323
295
267
355
305
278
252
382
329
300
272
361
310
282
256
354
302
239
286
227
358
306
242
290
230
365
312
247
295
234
372
317
251
301
238
61
62
63
64
65
and
Over
811
698
636
577
765
658
599
544
829
714
651
590
782
672
612
556
852
733
669
606
804
691
629
571
867
744
678
615
816
702
639
582
867
744
678
615
816
702
639
582
788
673
533
637
505
806
688
545
652
516
828
707
560
670
530
840
717
570
681
540
840
717
570
681
540
Age
Plan Name
30
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
392
337
307
279
370
318
289
263
381
325
257
308
244
44
45
46
35
36
37
Age
47
48
49
403
417
433
451
472
492
347
359
373
388
406
424
316
327
340
354
370
386
287
297
308
321
336
350
380
393
408
426
445
465
327
338
351
366
383
399
298
308
320
333
348
364
270
280
290
303
317
330
392
405
421
438
459
478
335
346
359
374
392
409
265
274
285
297
310
324
317
328
340
354
371
387
251
259
269
281
294
306
50
51
52
53
54
55
515
444
404
367
486
418
381
346
538
463
422
383
508
437
397
361
563
485
442
401
532
457
416
378
589
507
462
419
556
477
435
395
616
530
484
438
581
500
455
413
643
554
505
458
607
522
475
432
501
428
339
405
321
523
447
354
423
335
547
467
370
443
351
572
488
387
463
366
599
511
405
484
383
625
534
423
506
401
56
57
58
59
60
673
703
735
751
783
579
605
633
646
674
528
552
577
590
615
479
500
523
535
557
635
664
694
709
739
546
570
596
609
635
497
519
543
555
578
452
472
493
504
525
654
683
715
730
761
559
584
610
623
650
443
462
483
494
515
529
553
578
590
616
419
438
458
468
487
31
Individual and Family Plan Rates, Group C: Non-Tobacco user
Group C counties: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River,
Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
** Choice plans are not available for purchase in these Group C counties: Columbia, Gilliam, Grant, Harney, Jefferson,
Lake, Morrow, Sherman, Tillamook, Wasco, and Wheeler.
Plan Name
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
Age
0 to 20
188
162
147
134
177
152
139
126
183
156
123
148
117
101
21
22
23
Age
24
25
26
27
28
29
30
31
32
296
296
296
296
297
303
255
255
255
255
256
261
232
232
232
232
233
238
210
210
210
210
211
216
279
279
279
279
280
286
240
240
240
240
241
246
218
218
218
218
219
224
198
198
198
198
199
203
287
287
287
287
289
294
245
245
245
245
246
251
194
194
194
194
195
199
232
232
232
232
233
238
184
184
184
184
185
189
159
159
159
159
159
163
310
267
243
221
293
251
229
208
321
277
252
229
303
261
237
216
331
285
260
236
312
268
244
222
336
289
263
239
317
272
248
225
343
295
269
244
323
278
253
230
350
301
275
249
330
284
258
235
301
257
204
244
193
166
312
267
211
253
200
173
322
275
218
260
206
178
326
279
221
264
209
333
284
225
269
213
340
290
230
275
218
33
34
38
39
40
41
42
354
359
361
364
366
368
305
309
311
313
315
317
278
282
284
286
287
289
252
256
257
259
261
262
334
339
341
343
346
348
287
291
293
295
297
299
262
265
267
269
270
272
238
241
242
244
246
247
344
349
351
354
356
358
294
298
300
302
304
306
233
236
238
239
241
242
278
282
284
286
288
290
221
224
225
226
228
229
373
321
293
266
352
303
276
250
378
325
297
269
357
307
279
254
385
331
302
274
363
312
284
258
392
337
308
279
370
318
289
263
363
310
245
293
232
367
314
249
297
235
374
320
253
303
240
381
325
258
308
244
61
62
63
64
65
and
Over
831
715
652
591
784
674
614
558
850
731
667
605
802
689
628
570
873
751
685
621
824
708
645
586
888
765
696
630
837
720
654
594
888
765
696
630
837
720
654
594
808
690
546
653
517
826
705
559
668
529
849
725
574
686
543
861
735
582
696
552
861
735
582
696
552
Age
Plan Name
32
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
401
345
315
286
379
326
296
269
390
333
264
315
250
44
45
46
35
36
37
Age
47
48
49
50
51
52
53
54
55
413
427
444
462
484
505
356
368
382
398
416
434
324
335
348
363
380
396
294
304
316
329
344
359
390
403
419
436
456
476
335
346
360
375
392
409
305
315
328
341
357
373
277
287
298
310
324
338
402
415
431
449
470
490
343
354
368
384
401
419
272
281
292
304
318
332
325
336
349
363
380
397
257
266
276
288
301
314
528
455
415
376
498
428
390
354
552
475
433
393
521
447
407
370
577
497
453
411
545
468
426
387
603
519
474
429
569
489
446
405
631
543
496
449
596
512
466
424
659
568
518
469
622
535
487
442
513
438
347
415
329
536
458
363
434
343
561
479
380
454
359
586
501
397
474
376
614
524
415
496
393
641
547
434
518
411
56
57
58
59
60
690
721
754
770
803
594
620
649
663
691
542
566
591
604
630
491
513
536
548
571
651
680
711
727
757
560
585
611
624
651
510
532
557
569
593
463
484
506
516
538
671
700
732
748
780
573
598
625
639
666
454
474
496
506
528
542
567
592
605
631
430
449
469
479
500
33
Individual and Family Plan Rates, Group C: Tobacco user
Group C counties: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River,
Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
** Choice plans are not available for purchase in these counties: Columbia, Gilliam, Grant, Harney, Jefferson, Lake,
Morrow, Sherman, Tillamook, Wasco, and Wheeler.
Plan Name
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
Age
0 to 20
188
162
147
134
177
152
139
126
183
156
123
148
117
101
21
22
23
Age
24
25
26
27
28
29
30
31
32
325
325
325
325
327
333
280
280
280
280
281
287
255
255
255
255
256
261
232
232
232
232
232
237
307
307
307
307
308
314
264
264
264
264
265
270
240
240
240
240
241
246
218
218
218
218
219
223
316
316
316
316
317
324
270
270
270
270
271
276
214
214
214
214
215
219
256
256
256
256
257
262
203
203
203
203
203
207
175
175
175
175
175
179
341
293
268
243
322
277
252
229
354
304
278
252
334
287
261
237
364
313
286
259
344
295
269
244
369
318
290
263
348
300
273
248
377
325
296
268
356
306
279
253
385
331
302
274
363
312
284
258
331
283
224
268
212
183
344
293
233
278
220
190
354
302
239
286
227
195
359
306
243
290
230
366
313
248
296
235
374
319
253
303
240
33
34
38
39
40
41
42
390
395
398
400
403
405
335
340
342
344
347
349
306
310
312
314
316
318
277
281
283
285
287
289
368
373
375
378
380
383
316
320
322
325
327
329
288
292
294
296
297
299
261
265
267
268
270
272
379
384
386
389
391
394
323
328
330
332
334
336
256
260
261
263
265
267
306
310
312
315
317
319
243
246
247
249
251
252
411
353
322
292
387
333
303
275
416
358
326
296
392
337
307
279
424
365
332
301
400
344
313
284
431
371
338
307
407
350
318
289
399
341
270
323
256
404
345
273
327
259
412
352
279
333
264
419
358
283
339
268
61
62
63
64
65
and
Over
914
787
718
651
863
741
675
613
935
804
734
665
882
758
690
627
960
827
754
684
906
779
709
644
975
840
765
696
921
792
720
654
975
840
765
696
921
792
720
654
888
759
601
719
569
908
776
615
735
582
933
797
632
755
598
948
810
642
768
609
948
810
642
768
609
Age
Plan Name
34
Balance 1000 Gold*
Balance 4000 Silver
Choice 1000 Gold*
Choice 2000 Silver*
Choice 4000 Silver
Choice 6800 Bronze*
Connect 1000 Gold*
Connect 4000 Silver
43
441
380
346
314
417
358
326
296
429
366
290
347
275
44
45
46
35
36
37
Age
47
48
49
454
470
488
508
532
555
391
404
420
438
458
478
357
369
383
399
417
436
323
334
347
362
379
395
429
443
461
480
502
524
369
381
396
412
431
450
336
347
360
376
393
410
305
315
327
341
357
372
442
457
474
494
517
539
377
390
405
422
441
461
299
309
321
334
350
365
357
369
384
400
418
436
283
292
304
317
331
345
50
51
52
53
54
55
581
500
456
414
548
471
429
390
607
522
476
432
573
492
448
407
635
547
498
452
599
515
469
426
664
571
521
472
626
538
490
445
695
598
545
494
655
563
513
466
725
624
569
516
685
588
536
487
565
482
382
457
362
590
504
399
477
378
617
527
418
499
395
645
551
436
522
413
675
576
457
546
432
705
602
477
570
452
56
57
58
59
60
759
793
829
847
883
653
682
713
729
760
596
622
651
665
693
540
564
590
603
628
716
748
782
799
833
616
643
672
687
716
561
586
612
625
652
509
532
556
568
592
738
771
806
823
858
630
658
688
703
733
499
521
545
557
581
597
623
652
666
694
472
494
516
527
550
35
Other things to know as you
consider your coverage
Special Enrollment
Additional benefit notes
To apply for 2016 medical coverage or make a change
to your current plan outside of the open enrollment
period, you must qualify for special enrollment. You
can apply for and get health insurance coverage during
the special enrollment period if you lose your medical
coverage or experience certain life events, such as
marriage or adoption. For more information and a list
of qualifying events, visit ProvidenceHealthPlan.com/qe.
There is a waiting period of 12 months for elective
surgeries. Examples of elective surgeries include
arthroscopic cartilage repair, bunionectomy,
carpal tunnel surgery and tonsillectomy. If a
certificate of creditable coverage is provided,
we will credit days toward the waiting period.
Application and premium payment dates
Your paper or online application submitted
directly to Providence Health Plan needs to be
received by the requested effective date.
When you start coverage, your first health insurance
premium is due by the end of the first day of
coverage. For example, if your coverage start date is
Feb. 1, your payment must be received by Providence
Health Plan by the close of business on Feb. 1. On
a monthly, ongoing basis, your premium is due the
first day of the month. For your convenience, you
can set up auto-pay with your financial institution
or through your myProvidence account.
Non-preventive colonoscopies will be
covered under the in-patient or outpatient
surgical benefits (provider and facility).
Travel reimbursement benefits added
for 2016 non-transplant services:
Notes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
• If an in-network provider is not available
for your specific condition within 50
miles, we will reimburse travel to an innetwork provider up to 300 miles away
__________________________________________________________________________________________
• Reimbursement to closest in-network provider
__________________________________________________________________________________________
• Mileage reimbursement or per diem
($150) if overnight stay is required;
annual maximum benefit ($1,500)
• Must be medically necessary, and
prior authorization is required
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Eligibility
To purchase one of our plans, you must live in the service
area and be a legal resident of the state of Oregon.
In order to be eligible to enroll in the Providence
Progressive Dental Plan, you must enroll in a Providence
Health Plan Individual & Family medical plan.
Providence is Non-Duplication with Medicare on
Individual and Family plans. Someone who is entitled
to Medicare part A or enrolled in part B is not eligible
to enroll in a PHP Individual and Family plan.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Privacy policy
36
__________________________________________________________________________________________
Visit ProvidenceHealthPlan.com to learn about Providence Health Plan privacy practices. You may obtain
a copy of our Providence Health Plan Notice of Privacy Practices by going to ProvidenceHealthPlan.com
and selecting “Privacy Notices & Policies” or by calling customer service at 800-878-4445.
__________________________________________________________________________________________
37
38
Notes:
Notes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
39
Our Mission
As people of Providence,
we reveal God’s love for all,
especially the poor and vulnerable,
through our compassionate service.
Our Core Values
Respect, Compassion, Justice,
Excellence, Stewardship
Portland Metro Area
503-574-5000
All other areas
800-988-0088
Feb. 1, 2016 – Dec. 31, 2016: 8 a.m. to 8 p.m., Monday – Friday
Providence Health & Services, a not-for-profit health system, is an equal opportunity
organization in the provision of health care services and employment opportunities.
© 2016 Providence Health Plan. All rights reserved.
IND-016Q-1 (2/16) HP16-90094

2016 Plan Overview - Providence Health Plan

Transcription

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