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 Preferred Provider (PPB) Plan C 

Plan C is a high-deductible health plan which can be paired with a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA).

Major Plan Features:

Deductible
The annual deductible is $1,200 for employee-only coverage and $2,400 for employee and child(ren), family, or family with employee spouse coverage.

• This is a combined medical and prescription deductible.
• This deductible must be met before the plan begins to pay for medical services or prescription drug benefits.
• Unlike PEIA PPB Plans A and B, in Plan C the family deductible can be met by just one person, and the full amount of the family deductible must be met before the plan begins to pay.
• The following services are not subject to the deductible and are covered in full:
  • Routine prenatal care (physician services)
  • Well child exams and immunizations as recommended by the American Academy of Pediatrics
  • High risk birth score program
  • Annual screening mammogram
  • Annual Pap smear
  • Colorectal cancer screening age 50 + above
  • Prostate cancer screening age 50 + above
  • Adult Immunizations as recommended by the American Academy of Family Physicians
• Prescription Drugs on the Preventive Drug List are not subject to the deductible, but will be covered with normal copays of $5, $20 and $50, depending on their generic, preferred or non-preferred status. These copayments do not count toward the annual deductible, but DO count toward the out-of-pocket maximum.

Coinsurance
All medical services in this plan are subject to 20% coinsurance after the deductible is met. All coinsurance counts toward the out-of-pocket maximum. The only services excluded from coinsurance are:

• Routine prenatal care (physician services)
• Well child exams and immunizations as recommended by the American Academy of Pediatrics
• High risk birth score program
• Annual screening mammogram
• Annual Pap smear
• Colorectal cancer screening age 50 + above
• Prostate cancer screening age 50 + above
• Prescription Drugs (see Copayments below)
• Adult Immunizations as recommended by the American Academy of Family Physicians

Copayments
Prescription Drugs on the Preventive Drug List are not subject to the deductible, but will be covered with normal copays of $5, $20 and $50, depending on their generic, preferred or non-preferred status. All prescription drugs not on the Preventive Drug List will be covered with normal copays of $5, $20 and $50, depending on their generic, preferred or non-preferred status after the combined medical/prescription drug deductible is met. Copayments paid for drugs on the Preventive Drug List do not count toward the deductible. All in-network copayments count toward the out-of-pocket maximum.

Out-of-Pocket Maximum
In-network benefits have an out-of-pocket maximum of $2,400 employee only, and $4,800 employee and child(ren), family, or family with employee spouse This is a combined medical and prescription out-of-pocket maximum. All in-network coinsurance and copayments count toward this out-of-pocket maximum. Once the out-of-pocket maximum is satisfied, in-network services are covered at 100%.

There is no out-of-pocket maximum for out-of-network benefits in Plan C. The out-of-network benefit remains at 80%, regardless of the amount paid in coinsurance and copayments by the member.

Network
This is a Preferred Provider Benefit (PPB) Plan which uses the same network as PEIA’s other plans, and the same rules for using network providers. PEIA’s network consists of WV providers, some directly contracted providers outside WV, and the Aetna Signature Administrators (ASA) Preferred Provider Organization. Out-of-state network providers may change. For example, Kings Daughters Medical Center and Our Lady of Bellefonte hospitals in Kentucky and University of Pittsburgh Medical Center remain out-of-network for PEIA, regardless of their network status with the ASA PPO network. Also, PEIA does not use the ASA PPO network in Gallia or Washington County in Ohio, or in Boyd County, Kentucky. For information about specific providers, contact HealthSmart at 1-888-440-7342.

As with all PEIA PPB Plans, network requirements vary based upon the residency of the plan participant.

Resident PPB Plan Participants
PEIA PPB Plan participants who live in West Virginia or a bordering county of a surrounding state may access care from any of the following providers without receiving prior approval:
• any West Virginia health care provider who provides health care services or supplies to a PEIA
participant, or
• any network provider located in those bordering counties.

All services, except emergency care, provided outside of West Virginia beyond the bordering counties require prior approval.

Non-Resident PPB Plan Participants
For PEIA PPB Plan participants who reside outside the State of West Virginia (beyond the bordering counties of surrounding states), PEIA has made special arrangements. Participants who live more than one county outside the state may seek care from any network provider. Care from network providers does not require prior approval, and that care will be covered at the in-network benefit level (typically 80%). Precertification of inpatient stays and certain outpatient procedures is still required.

Out-of-network care is care provided by a provider who does not participate in PEIA’s network, as well as care from in-network, out-of-state providers (beyond the bordering counties of surrounding states) that is not approved in advance. This includes providers who are Aetna ASA participating providers that are physically located beyond the bordering counties of surrounding states. For non-contracted providers, PEIA will pay 80% of what it would have paid if the services had been provided in-West Virginia. You will be responsible for the 20% coinsurance and for any amounts that exceed the WV PEIA fee allowances. Those balance billing amounts are considered non-covered services, so they do not count toward the deductible, and there is no out-of-network out-of-pocket maximum, so there is no limit to the amount you may be required to pay under these circumstances. Members are always responsible for paying 100% of non-covered services.

Health Savings Account*
A health savings account (HSA), is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from the employer-owned Health Reimbursement Arrangement (HRA) that is an alternate tax-deductible source of funds paired with HDHPs. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier.

PEIA is making available an HSA program through Fringe Benefits Management Company (the vendor who runs the Mountaineer Flexible Benefits Plan), but a member can set up an HSA with any company or financial institution that offers them – including local banks. To access the funds, the member will receive medical services, and pay for them with funds from the HSA. With the HSA offered by Fringe Benefits Management Company, the member will receive a debit card that will draw funds from the HSA to pay for medical expenses. It is the member’s responsibility to account to the IRS for how the funds are spent.

*This section is informational only. PEIA cannot give tax advice. For more information on HSAs and taxation, consult your tax advisor.