Benefits » Health Insurance » PPO
As with the Select EPO plan, the LANS/LANL Options Preferred Provider Organization (Options PPO) medical insurance plan provides access to a large national provider network but also offers the option of seeking services from out-of-network providers. The Options PPO plan design is similar to the Blue Cross Blue Shield Point-of-Service New Mexico plan, but it is split into several parts with separate rate structures: Options PPO New Mexico, Options PPO National, and Options PPO Out-of-Area.
The Options PPO New Mexico plan is for LANS employees and retirees who live in New Mexico and want more choice in providers than the Select EPO plan provides.
The Options PPO National plan is for LANS employees and retirees who live in the UnitedHealthcare service area outside of New Mexico.
The Options PPO Out-of-Area plan is for LANS employees and retirees who live outside the UnitedHealthcare service or live abroad. If you are in this category and live in Nevada or the Washington, DC, area, you will continue to have other plans available (such as PacifiCare of Nevada and Kaiser Permanente Mid-Atlantic for Washington, DC) , along with the Select EPO plan. If you do not live in these areas, this medical plan is the only one available to you.
| Calendar-Year Deductible* | Out-of-Pocket Maximum | Office Visit | |
|---|---|---|---|
New Mexico PPO |
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| In-network | Individual: $250 Family: $750 (max.) | Individual: $3,000** Family: $9,000 (max.)** | $20 (no charge for children under 2) |
| Out-of -network | Individual: $500 Family: $1,500 (max.) | Individual: $6,000** Family: $18,000 (max.)** | 40% |
National PPO |
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| In-network | Individual: $250 Family: $750 (max.) | Individual: $3,000** Family: $9,000 (max.)** | $20 (no charge for children under 2) |
| Out-of- network | Individual: $500 Family: $1,500 (max.) | Individual: $6,000** Family: $18,000 (max.)** | 40% |
Out-of-Area PPO |
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| Individual: $250 Family: $750 (max.) | Individual: $3,000 Family: $9,000 (max.) |
10% | |
| * Visit copayments, emergency room, and inpatient hospital copayments are not subject to and do not apply to the calendar year deductible | |||
| ** Under the Medical portion of the PPO plan, the PPO In-Network calendar year deductible, visit and emergency copayments, and coinsurance apply to the annual Out-Of-Pocket limit amount | |||
Members of the Options PPO plan are able to see any physician or go to any facility in New Mexico or the United States. The employee-paid premium is higher than those for the Select EPO, but after an employee/retiree reaches the out-of-pocket limit, the plan will cover eligible expenses at 100%.
The Options PPO New Mexico plan has the highest employee-paid premium of any plan.
Options PPO network doctors' visits have a $20 copayment with additional charges for such procedures as x-rays, blood tests, MRIs, and other lab work paid at 90/10 coinsurance split once the deductible is met. (There is a 60/40 coinsurance split if you select an out-of-network provider.) Well-baby care is covered at 100% up to age 2 years.
The calendar year deductibles, out-of-pocket-maximums, maximum benefits, and individual plan benefit limits are combined for a member who transfers among the three Options PPO plans.
Additional benefits available to Lab employees include hearing aids, covered at 50% or a maximum of $2,000 per ear in a period of 36 months; surgery for the morbidly obese; 20 visits each for physical therapy, occupational therapy, and speech therapy; and coverage for Christian Science practitioners. Chiropractors and acupuncturists are covered as they have been previously.
The Benefit Eligibility Level Codes (pdf) for Options PPO are 1, 2, and 3. The areas covered for Options PPO are restricted to zip codes in New Mexico, Washington, D.C. and Nevada Test Site. The zip codes for Options PPO/OOA must be out of any UHC network area.
New Mexico does not recognize "common law" marriages; therefore, only a legal spouse or eligible domestic partner may be enrolled in LANS sponsored health and welfare plans.
You may enroll yourself or an eligible family member in a LANS-sponsored medical plan if you are a newly-hired employee, have a qualified change of status, or during Open Enrollment, which is held at the Lab each November, with coverage effective January 1st of the following year.
If you are newly hired, you have a period of initial eligibility (PIE) during which you may enroll yourself and your eligible family members. Your PIE starts the day you become eligible—usually on your date of hire—and ends approximately 31 days later.
To enroll, submit a completed insurance enrollment form (pdf) to the Lab’s Benefits Office within 31 days of your PIE.
You may become eligible for LANS-sponsored benefits if you change employment status (e.g., change from contractor to LANS or limited benefits to full benefits). When this happens, contact the Lab's Benefits Office immediately by calling 505-667-1806 or e-mail the Benefits Office to determine when your PIE begins and to register for a benefits presentation. You will have a 31-day PIE from the date your employment status was changed
Families change and grow due to marriage, birth or adoption of children, and other events. If enrolling in a medical plan because of a family status change (e.g., marriage or birth of a child), you must request enrollment within 31 days from the date of the qualifying event (e.g., date of marriage or date of the child's birth).
To enroll, contact the Lab’s Benefits Office at 505-667-1806 or e-mail the Benefits Office.
If you are not enrolled in a medical plan, you and your eligible family members may enroll during Open Enrollment, which is usually held in November for coverage effective January 1st of the following year.
If you and/or an eligible family member involuntarily lose other employer-sponsored medical insurance coverage, you may enroll in one of LANS’s medical plans. A new PIE starts the day you lose coverage. You must furnish proof that other employer group coverage was lost.
To enroll e-mail the Benefits Office or call 505-667-1806.
If you are going on or returning from a change of station or extended travel and will be moving in or out of a service area, you may be able to change your insurance plan. Contact the Lab’s Benefits Office at 505-667-1806 or e-mail the Benefits Office about this change.
If you missed your PIE, you can still enroll in medical coverage at any time by submitting an enrollment form to Benefits; however, your medical coverage won’t go into effect for 90 calendar days from the day you submit your form.
After deciding whether to choose a provider in the United Healthcare Options PPO network or seek services through an out-of-network provider, members can self-refer to a specialist for care.
LANL employees enrolled in a UnitedHealthcare plan can now easily access information on claim status. This on-line service is provided by UnitedHealthcare and allows you to:
Insurance card. If you don’t receive your UnitedHealthcare card within several weeks of enrollment (45+ days) contact UnitedHealthcare directly at 1-800-603-3816.
Contact customer service. To change your PCP, inquire about claims or covered services contact the UnitedHealthcare LANL representative.
Dispute with UnitedHealthcare. You should first contact UnitedHealthcare customer service directly at 1-800-603-3816 to resolve the issue. If you are unsuccessful in resolving the issue through this route, you can meet with the LANL UnitedHealthcare representative.
This is only an overview of the Options PPO medical insurance plan. For full details, refer to the Options PPO New Mexico Plan/Options PPO National Plan Summary (pdf) and the Options PPO Out-of-Area Plan summary (pdf).
Questions? Contact the Lab's Benefits Office at 505-667-1806.