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Transition to New Operating Platform FAQ

Helpful information about our new claims processing system.

Coinsurance

Coinsurance is a percentage (for example 30%) you pay toward the cost of certain Covered Services. The plan will pay the remaining amount. Unless specified on your Schedule of Benefits, coinsurance begins once you have met your deductible.

Copayments (Copays)

A copayment is a fixed amount (for example, $15) you pay for a covered healthcare service, usually at the time you receive the service. Unless specified on your Schedule of Benefits, the deductible does not have to be met for the application of a copayment. The amount can vary by the type of covered healthcare service. Copayments do not count toward your deductible. Copayments do count toward your out-of-pocket maximum.

Covered Services

Covered services are the goods or services that the plan will help you pay as outlined in the Member materials. Your Member materials include the Member Benefit Agreement, Schedule of Benefits, and Summary of Benefits and Coverage.

Deductible

The deductible is the amount you pay for certain covered services before the plan pays benefits. If your plan covers more than one person, there will be both an individual deductible and a family deductible. Any one Member covered under your policy only needs to meet the individual deductible, while the other Members of your family combine to meet the remainder of the family deductible.

Out-of-Pocket Costs

Out-of-pocket costs are the costs you pay. Maximum out-of-pocket costs are the total of your copays, coinsurance, and deductible payments that you will be expected to pay.

Prescription Drug Formulary

We cover prescription medicines that are proven effective and list these drugs on a “formulary.” Go to HealthOptions.org/Formulary to see our complete formulary.

Primary Care Provider

Your Primary Care provider (or PCP) is a family doctor, nurse practitioner, pediatrician or other provider with whom you maintain a long-term relationship. Your PCP is a partner in your healthcare who will advise you and provide treatment on a range of health-related issues. He or she may assist you in your interactions with specialists.

Online Authorizations Demonstration

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