Selecting Your Plan
Understanding Your Plan Options
After reviewing some things to consider when comparing plans, you should understand the differences between plan types and find out which plans you’re eligible to enroll in. Currently, STRS Ohio provides access to four types of plans:
Your eligibility for plan types depends on the geographic location of your permanent residence and your Medicare status on file with STRS Ohio. As a result, you may find that some plan types or plan administrators may not be available to you or your family.
It’s important to note that you and your family must enroll in a plan offered by the same plan administrator. In addition, if you’re enrolling in a Basic or Plus Plan, you and your family must enroll in the same plan level. For example, if you decide that the Medical Mutual Basic Plan is right for you, you and all your eligible dependents must enroll in the Medical Mutual Basic Plan.
Unlike plan levels, which are determined on a family basis, eligibility for indemnity and PPO plans is determined individually based on where you live and your Medicare status. This means, for example, it’s possible for you to be enrolled in a PPO plan and an eligible dependent to be enrolled in an indemnity plan offered by the same plan administrator.
When comparing plans, keep in mind that prescription drug coverage is included in all of the health care plans we offer. This means you do not need to purchase additional prescription drug coverage or enroll in a supplemental prescription drug plan, such as Medicare Part D.
Under each plan, you will pay less for generic drugs compared to brand-name drugs. Your out-of-pocket expenses for prescription drugs will vary depending on the type of prescription drugs you purchase:
- Tier 1 (generic) or formulary generic — lowest copayment
- Tier 2 (select brand-name) or formulary brand-name — higher copayment than generic
- Tier 3 (other brand-name) or nonformulary brand-name — highest copayment
Some plans may also cover specific over-the-counter medications for a lower copayment, as well as designated double-strength medications that can be split in half by the recipient to get the prescribed lower strength.
STRS Ohio is working hard to keep your prescription drug coverage affordable. By selecting generics whenever possible, you save money and help reduce expenses for the STRS Ohio Health Care Program.
Key Terms to Understand
When reviewing plan types, it’s important to understand five key terms:
- Annual deductible — This is the dollar amount you must pay before the plan pays a portion of your hospital/medical costs.
- Coinsurance — This is the percentage of covered charges you must pay after you have met your annual deductible, such as 20% for a physician office visit.
- Copayment — This is the fixed amount you pay for a specific service, such as $10 for a generic drug.
- Monthly premium — This is the fixed amount you pay monthly for health care coverage under the plan. This amount must be paid regardless of which services, if any, you use.
- Out-of-pocket maximum — This is the amount you must pay in a calendar year before the plan pays 100% of remaining expenses for covered services that year. This amount does not include the annual deductible, prescription drug copayments and any charges exceeding UCR fees set by the health care plan administrator.
- Usual, customary and reasonable (UCR) fees — This is the predetermined amount a plan administrator will pay a provider for a medically necessary service. It is typically based on what is considered a “reasonable” charge for a particular service in your geographic area.
Indemnity Plans
What is an indemnity plan?
An indemnity plan is “traditional” health care coverage in which reimbursement is made either to you or directly to your doctor, up to a predetermined dollar amount or coverage limit determined by the plan administrator. You are responsible for any charges exceeding this amount or limit. As an enrollee, you can use any health care provider, which means you do not need to use in-network providers to reduce your out-of-pocket expenses.
Your out-of-pocket expenses include the annual deductible, coinsurance, copayments, monthly premium and any charges exceeding UCR fees set by the health care plan administrator.
Which indemnity plans are offered?
- Aetna Basic Indemnity
- Aetna Plus Indemnity
- Medical Mutual Basic Indemnity
- Medical Mutual Plus Indemnity
Are you eligible for an indemnity plan?
You are eligible for an Aetna or Medical Mutual indemnity plan if:
- You are enrolled in Medicare Parts A & B, or
- You live outside a PPO-network area, regardless of your Medicare status.
PPO Plans
What is a PPO?
A preferred provider organization (PPO) is a group of selected health care providers who have agreed to offer comprehensive services at preset reimbursement levels. These providers —
including physicians, hospitals and other health care providers — are referred to as “in-network” providers. As an enrollee, you can use out-of-network providers, but your out-of-pocket expenses will be higher.
Your out-of-pocket expenses include the annual deductible, coinsurance, copayments, monthly premium and any charges exceeding UCR fees set by the health care plan administrator.
Which PPO plans are offered?
- Aetna Basic PPO
- Aetna Plus PPO
- AultCare PPO (no sponsored dependent coverage)
- Medical Mutual Basic PPO
- Medical Mutual Plus PPO
Are you eligible for a PPO plan?
You are eligible for an Aetna or Medical Mutual PPO plan if:
- You are not enrolled in Medicare Parts A & B, or
- You are enrolled in Medicare Part B only and live in a PPO-network area.
You are eligible for AultCare PPO if:
- You live in a select ZIP code in the Canton, Ohio, area and you are not enrolled in Medicare Parts A & B.
Commercial HMO PLANS
What is a commercial HMO?
A commercial health maintenance organization (HMO) is a health plan in which physicians, hospitals and other health care providers either contract with or are employed directly by the HMO to provide services. Commercial HMOs are only available in select ZIP codes within Ohio and select areas in Michigan.
Your out-of-pocket expenses include the coinsurance, copayments and monthly premium. There is no annual deductible.
Which commercial HMO plans are offered?
- Kaiser Permanente (no sponsored dependent coverage)
- Paramount Health Care
Are you eligible for a commercial HMO plan?
- You are eligible for Kaiser Permanente if you reside in a select ZIP code in the Cleveland, Ohio, area and you are not enrolled in Medicare.
- You are eligible for Paramount Health Care if you reside in a select ZIP code in the Toledo, Ohio, area or select areas in Michigan, regardless of your Medicare status. (Note: If you are enrolled in Medicare, you retain your Medicare coverage under this plan. This means that Medicare — not Paramount Health Care — covers services provided by Medicare-approved providers who do not participate in the HMO.)
Medicare HMO Plans
What is a Medicare HMO?
A Medicare HMO is a health care plan in which the federal government reimburses the HMO to provide the enrollee with basic Medicare coverage and other benefits, such as coverage for routine physical exams and low copayments for office visits. Additional benefits, such as coverage for Medicare deductibles, coinsurance, preventive services, prescription drugs, certain dental services and other care not normally covered under Medicare, are usually provided. Medicare HMOs are only available in select ZIP codes in the Cleveland and Toledo, Ohio, areas, as well as select areas in Michigan.
When you enroll in a Medicare HMO, your original Medicare Parts A & B benefits are assumed by the Medicare HMO plan. You will still be responsible for paying your monthly Medicare Part B premium to Medicare if you choose to enroll in a Medicare HMO.
Your out-of-pocket expenses include the coinsurance, copayments and monthly premium. There is no annual deductible.
Which Medicare HMO plans are offered?
- Kaiser Permanente Medicare Plus (no sponsored dependent coverage)
- Paramount Elite
Are you eligible for a Medicare HMO plan?
You are eligible for Kaiser Permanente Medicare Plus if:
- You are enrolled in Medicare Parts A & B or Medicare Part B only and you reside in a select ZIP code in the Cleveland, Ohio, area.
You are eligible for Paramount Elite if:
- You are enrolled in Medicare Parts A & B and you reside in a select ZIP code in the Toledo, Ohio, area or select areas in Michigan.
- You are enrolled in Medicare Part B only, you reside in a select ZIP code in the Toledo, Ohio, area or select areas in Michigan and you were enrolled in a Medicare HMO as of
Dec. 31, 1998.
Enrollees who have end-stage renal disease (who are not currently enrolled in a Kaiser Permanente or Paramount health care plan) and enrollees who have received a kidney transplant within the past 36 months are not eligible to enroll in a Medicare HMO. Also, under most Medicare HMOs, if you reside outside the select ZIP code for more than 90 consecutive days a year, you are not eligible to enroll.
