Learn about changes to your health coverage for 2016

All changes are effective January 1, 2016.


 

New medical plan options

Next year, the PEBB Program will offer three new medical plan options.

Group Health will offer SoundChoice with the same high-quality, coordinated services and same benefits and exclusions as Group Health’s Classic and Value plans, but at an even lower monthly premium. Group Health SoundChoice will be available in King, Pierce, Snohomish, and Thurston counties.

Uniform Medical Plan (UMP) will offer UMP Plus, a new medical plan that takes what PEBB members like about UMP and adds more. Members can select UMP Plus through Puget Sound High Value Network or UW Medicine Accountable Care Network. Both networks are available in King, Kitsap, Pierce, Snohomish, and Thurston counties.

Why is the PEBB Program offering these new options?
These new plans are a key part of paying for value, a core strategy of Healthier Washington. The goal is to achieve better health and better care at lower costs. Visit www.hca.wa.gov/hw to learn more.

 

Medical plan benefits

The changes shown below affect the plans noted.

Other medical benefits won’t change in 2016; but keep in mind, costs for prescription drugs can change at any time as drugs move into different tiers.

Group Health will:
  • Cover cardiac rehabilitation under the physical, occupational, and speech therapy benefit with a combined limit of 60 inpatient days and 60 outpatient visits per year. (All Group Health non-Medicare plans)
  • Increase the per-visit copay from $15 to $30 (Group Health Classic) and from $20 to $40 (Group Health Value) for the following provider types:
    • Audiologist
    • Enterostomal therapist
    • Massage therapist
    • Nutritionist
    • Occupational medicine
    • Occupational therapist
    • Physical therapist
    • Respiratory therapist
    • Speech therapist
  • Offer a lower cost-sharing when receiving some services and prescription drugs from Group Health-designated providers. (Group Health Consumer-Directed Health Plan [CDHP])
  • Offer a broader Access PPO network. (Group Health CDHP only)

  • Implement changes listed under:
Kaiser Permanente will:
  • Increase its annual deductible to $300 per person, $900 per family. (Kaiser Permanente Classic)
  • Increase copays for office visits (Kaiser Permanente Classic):

    • Hearing: $35
    • Mental health: $25
    • Primary care: $25
    • Specialty care: $35
    • Spinal manipulations: $35
    • Urgent care: $45
    • Vision care*: $25
      *Ophthalmology visits will have a $35 copay.
  • Change emergency room costsharing to 15% coinsurance (annual deductible still applies). (Kaiser Permanente Classic)

  • Add new cost-sharing for medications administered during an inpatient, outpatient, or office visit: 15% coinsurance (annual eductible and separate copay for type of visit still applies). (Kaiser Permanente Classic)
  • Increase the annual medical out-of-pocket maximum to $5,100 per person/$10,200 per family. (Kaiser Permanente CDHP)

  • Change its prescription drug tiers and costs (Kaiser Permanente Classic and CDHP)
     
    Prescription drug tiers
    Retail pharmacy
    Mail order
    Tier 1 – Generic
    $15
    $30
    Tier 2 – Preferred brands
    $40
    $80
    Tier 3 – Non-preferred brands
    $75
    $150
    Tier 4 – Specialty
    50% up to $150
    50% up to $150
  • Expand out-of-area coverage for enrolled dependent children to include 10 office visits, 10 lab/x-ray visits, and 10 prescription-drug refills per year without preauthorization. (Kaiser Permanente Classic and CDHP)

  • Implement changes listed under:

Uniform Medical Plan (UMP) will: Implement changes listed under:
For more details about your 2016 medical benefits, contact your plan.


Benefit changes for all non-Medicare Group Health, Kaiser Permanente, and UMP plans

  • Expand coverage for end-of-life counseling.

  • Provide coverage for short-term alcohol and substance abuse treatment in various settings, by various provider types.

  • Expand coverage for preventive services including:

    • Tobacco cessation quit medications and aids—Coverage for all medications and nicotine replacement therapy with a prescription.

    • Coverage for eight new preventive services with no member cost-sharing:

      1. Sexually transmitted infections—Provide intensive behavioral counseling for sexually active adolescents and adults at increased risk.

      2. Chlamydia and gonorrhea—Screen sexually active women ages 24 or younger, and older women based on risk.

      3. Hepatitis B—Screen non-pregnant adolescents and adults at high risk.

      4. Cardiovascular disease—Offer or refer adults at risk to intensive behavioral counseling.

      5. Dental caries (cavities)—Prescribe fluoride at age 6 months when water supply is fluoride-deficient; also provide fluoride varnish at primary tooth eruption.

      6. Abdominal aortic aneurysm—Screen men ages 65-75 via ultrasonography if they have ever smoked.

      7. Gestational diabetes mellitus—Screen pregnant women with no symptoms after 24 weeks of pregnancy.

      8. Preeclampsia—Use low-dose aspirin after 12 weeks of pregnancy for women at high risk for preeclampsia.

 

Medical plan premiums

Except for those enrolled in UMP Classic, employees will see changes to their monthly premiums in 2016. See 2016 employee monthly premiums.

 

Medical out-of-pocket limits for family accounts enrolled in consumer-directed
health plans (CDHPs)

In 2016, the Group Health, Kaiser Permanente, and UMP CDHPs will pay 100 percent for covered benefits for individual family members who meet certain out-of-pocket limits, even if the family out-of-pocket limit has not been reached.

Annual medical out-of-pocket limits for families in 2016:

 
Group Health CDHP
Kaiser Permanente CDHP
UMP CDHP
$10,200 per family

If a family member reaches $5,100 in eligible out-of-pocket costs, the plan will pay 100% for covered benefits for that family member.
$8,400 per family

If a family member reaches $6,850 in eligible out-of-pocket costs, the plan will pay 100% for covered benefits for that family member

 

Family contribution amounts for the health savings account (HSA)

The annual HSA contribution limit for a family account (subscriber and at least one family member enrolled on the CDHP) will go up to $6,750 in 2016. (The contribution amount for an individual stays the same at $3,350.) Subscribers ages 55 and older can continue to contribute $1,000 more in addition to these amounts.

The amounts include contributions made by both you and your employer. Remember to include the $125 SmartHealth wellness incentive if you earned it for 2016. See more information on HSAs.

 

Supplemental life insurance premiums

Employees enrolled in PEBB’s supplemental life insurance through ReliaStar Life Insurance Company will see lower premiums for 2016.

See 2016 life insurance premiums.

 

Optional long-term disability insurance premiums

Employees enrolled in PEBB’s optional long-term disability (LTD) insurance through Standard Insurance Company will see higher premiums for 2016.

See 2016 optional LTD insurance premiums.


Employees can waive enrollment in PEBB medical for TRICARE retiree coverage

Employees may waive enrollment in PEBB medical if eligible for and enrolled in TRICARE as a retiree or a dependent of a retiree. This opportunity will only be during open enrollment or a special open enrollment event. To waive PEBB medical, go to My Account during open enrollment or use the 2016 Employee Enrollment/Change form.

 

SmartHealth wellness incentive deadlines

  • For eligible subscribers continuing enrollment in PEBB medical, the deadline to complete the SmartHealth program requirements to receive a PEBB wellness incentive the following year is September 30.

  • For eligible subscribers enrolling in PEBB medical with an effective date in January, February, March, April, May, or June the deadline to complete the SmartHealth program requirements to receive a PEBB wellness incentive the following year is September 30.

  • For eligible subscribers enrolling in PEBB medical with an effective date in July or August, the deadline to complete the SmartHealth program requirements to receive a PEBB wellness incentive the following year is 120 days from the subscriber’s PEBB medical effective date.

  • For eligible subscribers enrolling in PEBB medical with an effective date in September, October, November, or December, the deadline to complete the SmartHealth program requirements to receive a PEBB wellness incentive the following year is December 31.