| Frequently Asked Questions |
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What is a deductible?
A deductible is a specific flat-dollar amount an individual must pay out of their own pocket toward covered expenses before a plan begins to pay toward expenses. Deductibles carry through a twelve-month period – October 1 through September 30. Plan deductibles are listed on the summary of benefits or in your employee benefit booklet. To obtain the Summary of Benefits go to http://www.oregon.gov/DAS/OEBB/summaryofbenefits.shtml or call 1-888-4my-OEBB to request a copy.
Some plans have a family maximum annual deductible. Basically, this means that once a certain number of your family members meet the annual deductible, services for all family members will be paid at the plan benefit level. For example, if a plan has a $100 individual deductible, and a family deductible of $300 (shown as $100/$300 in the summary of benefits), once an individual has paid $100 for covered services, benefits would kick in at the benefit level for the type of service received for the remainder of the twelve-month benefit year. If two more family members meet their $100 deductible, for a combined family deductible amount of $300, no additional family members will need to meet their deductibles.
What are co-payments?
Copayments are pre-determined, flat-dollar fees for certain services (e.g., office visits) paid at the time of service. Typically, you don’t have to meet the plan deductible before receiving the benefit of a co-payment., Copayments usually don’t apply toward the maximum out-of-pocket and will be required even after the out-of-pocket maximum is reached.
What is an out-of-pocket maximum?
An out-of-pocket maximum is also referred to as the “stop loss” amount. Once you have paid that amount out of your pocket for covered services, you no longer pay for most covered services. Out of pocket maximums are calculated on an individual basis.
- Here is an example of how this works on a plan with a deductible, coinsurance and a copayment: Using OEBB Medical Plan 3 – 1) you pay the first $100 in covered services; 2) you pay 10% of the next $5,000 in covered services (or $500); and 3) the plan pays 100% of all costs for covered services through the remainder of the benefit year (October 1 through September 30). In this example, you would continue to pay $10 for each in network office visit. Under OEBB Medical Plan 3, the office visit copayments do not apply to the deductible or the maximum out-of-pocket.
- Here is an example of how this works on a plan with no deductible and no coinsurance, just copayments: Under OEBB Medical Plan 2 (either the Kaiser or Providence Health Plan option), your copayments apply toward the maximum out-of-pocket. If you use in network providers, you would pay your copayment ($5 for office visits or $100 for each emergency room visit) until you’ve paid out $600 in the benefit year (October 1 through September 30). If you meet that $600 maximum, then all covered services received using an in network provider would be covered in full through the remainder of the benefit year (October 1 through September 30).
Will my copays go toward my deductible and out-of-pocket?
Copays on OEBB Medical Plans 1 and 2 (with either Kaiser or Providence Health Plan) will count toward the maximum out-of-pocket. Copays made for OEBB Medical Plans 3 through 9 (offered through ODS Health Plan) will not count toward the deductible nor the out-of-pocket maximum.
Will the district have an opportunity to change plans with OEBB?
Districts will have the opportunity to make plan selection changes for the next open enrollment period (2009). Plan selection changes will need to be submitted to OEBB by May 31, 2009, for the 2009-10 plan year.
Will dental coverage start over at 70 percent or will employees be given credit for the incentive level they have earned? What if the employee was not in an incentive level plan prior to joining OEBB?
The level of coverage a member receives will be credited by OEBB based on the employee’s date of hire. For example, employees with three or more years of service that choose to enroll in one of the incentive dental plans (OEBB Dental Plans 1 through 3) will come into the program at the 100 percent benefit level. To maintain that level, the member must receive routine cleaning and maintenance care each year thereafter. Otherwise, the coverage will decrease by 10 percent the following year.
What is a benefit year? What is a plan year?
A benefit year refers to the twelve-month period that deductibles, out-of-pocket maximums, or any annual benefit maximums accrue or apply. A plan year refers to the twelve-month period designated for the purpose of providing annual open enrollment periods, benefit changes, rate changes and/or contractual changes between an insurance carrier and the benefit plan sponsor (e.g., OEBB).
OEBB’s benefit year and plan year are the same -- October 1 through September 30.
Will retirees be able to select a tiered rate even if the active employees in their employee group choose composite?
OEBB will allow retirees of an employee group using a composite rate structure to move to a tiered rate structure. If an employee group has a tiered rate structure then all retirees from that employee group will remain on a tiered structure.
What benefits will OEBB offer?
OEBB will offer medical, dental and vision benefit plans beginning October 1, 2008.
How will I enroll in benefits for October 1, 2008?
Open enrollment will be August 15 through September 15, 2008.
OEBB members will be able to enroll in benefits via an online enrollment system. The system, called MyOEBB, is web-based and will allow members to enroll from any computer in the world that has an Internet connection. It is a simple, four-step process including adding dependents. For those needing paper enrollment forms, OEBB will make those available to districts during the first two weeks in August. Enrollment forms can be obtained from your school or educational entity, or from OEBB.
Will OEBB’s plans be chosen by the Board or by the district?
The Board created nine medical plans, four pharmacy plans, eight dental plans, and five vision plans which are available to districts statewide. Each district can either select or allow an employee group to select the plans an employee group will have available to them, with some limitations.
OEBB plans are not one-size-fits-all. OEBB looked at all the 89 medical plans currently offered to district employees throughout the state and designed plans that are comparable to those plans. Employee groups within each district will be able to select:
- up to four OEBB medical plans;
- up to three OEBB dental plans (with or without orthodontia);
- one vision plan; and
- one pharmacy plan to be included with each medical plan option.
There are a couple of caveats to the above. For example, orthodontia must be offered with all dental plan offerings or must be omitted from all plan offerings. If an employee group offers a Kaiser medical plan and elects to offer a vision program through Kaiser, it can offer one other vision plan option. Regarding pharmacy, participating districts may choose or allow one pharmaceutical plan for each medical plan selected with the following restrictions: the HMO pharmaceutical plan (Pharmacy Plan 1) must be selected for OEBB Medical Plans 1 and 2; a participating district may only choose or allow Pharmacy Plan A, a combination of Pharmacy Plan A and Pharmacy Plan C, Pharmacy Plan B or a combination of Pharmacy Plan B and Pharmacy Plan C on OEBB Medical Plans 3 through 8; a participating districts cannot choose or allow an OEBB medical plan, even if it is matched with different pharmacy plans, for more than one of the up to four medical plan options available.
Will I have a choice between plans?
You can choose from the plans that are available to your employee group. An employee group is defined by the type of position you hold at the district and whether you are represented by a union. For example, classified employees represented by OSEA are considered one employee group; licensed employees represented by OEA are considered one employee group; classified non-represented employees are considered one employee group; and confidential non-represented employees are considered one employee group; etc.
Will districts be able to return to previous insurance plans they had prior to entering OEBB?
No. Once a district or employee group enters OEBB, they will not be able to use plans from any other carrier than those offered through OEBB. This is a requirement of the legislation that created the insurance pool, since the success of the program is dependent on the number of people enrolled in OEBB plans and the stability of the pool.
What are some of the covered services of the OEBB plans?
Of the many covered services included in the medical plan designs, a sampling includes: hospital benefits, newborn nursery care, emergency room care, outpatient surgery, chemotherapy, allergy injections, family planning, diabetes self-management programs, reconstructive surgery following a mastectomy, chiropractic, acupuncture, naturophathic, maternity care, well-baby care, hospice respite care, home healthcare, infusion therapy, rehabilitation, and injectable medications.
A complete list of printable plan designs is available on the OEBB Web site along with the details of each plan at www.oregon.gov/das/oebb.
Is weight-loss surgery covered?
At this time, coverage for services, supplies and surgery for weight loss and obesity will not be covered by OEBB.
Are there benefits OEBB will not offer?
Yes. For plans offered during the 2008-09 plan year, the Board will only provide core benefit plans – medical, dental and vision. However, the Board will continue to research and discuss offering non-core benefits – life, disability, long-term care, dependent care and healthcare spending accounts, health reimbursements accounts, and accidental death and dismemberment.
Will OEBB’s plans cover pre-existing conditions?
There will be no new pre-existing condition limitations; however a waiting period will apply for Dental and Vision services that are not considered preventative if the following applies:
Coverage for previously OEBB-eligible employees or a previously OEBB-eligible dependent enrolling in the dental and/or vision plans during an open enrollment period will be limited to routine and preventive care for the first 12 months and subject to a 12-month waiting period for orthodontia coverage. Eligible employees who enroll in the dental or vision plans, or add previously OEBB- eligible dependents to the dental and vision plans, due to a loss of other coverage will not be subject to waiting periods.
Where can I find OEBB’s plan designs?
Copies of OEBB’s plan designs, plan comparability, actuarial values and an explanation of the plan design process are on OEBB’s Web site, www.oregon.gov/das/oebb.
What impact will moving to OEBB have on district pools?
The movement to OEBB should have no impact on district benefit pools.
Will OEBB offer tiered rates, composite rates, or both?
OEBB will offer both composite and tiered rate structures for districts to consider during collective bargaining negotiations or management policy development. However, OEBB will not allow districts to offer both composite and tiered rates for the same type of benefit within an employee group. For example, if the district offers a tiered rate structure to classified represented employees for the medical plans, then all medical plans for that employee group must use a tiered rate structure.
Will districts be required to send premium payments to OEBB or the plan providers?
Districts will send premium payments to OEBB for disbursement to plan carriers.
For what services will OEBB bill districts?
OEBB will bill districts only for the premium amount listed on our Web site used to cover the employees and/or dependents who have elected coverage at the rate structure (composite or tier) that is being offered by the district.
Which carriers did OEBB select?
ODS Health Plan, Providence Health Plan, Kaiser Permanente, and Willamette Dental Group.
Who is going to be part of OEBB’s preferred provider list?
The preferred providers for ODS and Providence are on their Web sites. To search, or for more information, visit www.odscompanies.com/oebb or www.providence.org/oebb.
Willamette Dental and Kaiser facilities can be found at their respective Web sites including www.willamettedental.com and www.my.kp.org/nw/oebb.
What is the eligibility age of dependents?
Biological, step and adopted children under age 19 are eligible for coverage under OEBB benefit plans. Eligible employees also may obtain coverage for dependent children that are legal wards of the court or that they, their spouses, or domestic partners are required to support.
Dependent children age 19 up to 26 are eligible for coverage if they are:
- Attending school full time, excluding foreign students; or
- Living in the home of the eligible employee more than six months of the calendar year, and the eligible employee provides over half the yearly support; or
- Incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability.
Dependent children older than age 26 are eligible for benefit coverage if they are incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability and were covered under a district plan prior to reaching the age of 26. There are some exception, please see your district with questions.
Dependent children of all ages must be unmarried and not have a domestic partner to participate in OEBB-sponsored benefit plans.
A complete version OEBB’s eligibility rules are at www.oregon.gov/das/oebb.
Does my doctor participate with ODS Health Plans or Providence Health Plans?
OEBB will soon release the lists of providers that are in the ODS and Providence networks. Until then, you may go to the carrier Web sites and access their provider directories or use the search feature to find your provider or providers located in your area. Below are links that will take you to the provider directory or search feature on the carriers’ Web site.
ODS Health plans:
Provider Search, click here:
https://www.odshealthplans.com/provSearch/networkProviderSearch.do?hiddenRequestType=networkProviderSearch&networkProviderGroup=ODS&action=Go
Providence Health Plans:
Provider Search, click here: https://www.providence.org/PHP_ProviderDirectory/Pages/PHP/EnterSelections.aspx
Provider Directory, click here:
https://www.providence.org/php_providerdirectory/default.aspx?HealthPlanID=16007
What carriers will provide dental coverage?
Dental Coverage will be provided through the following carriers.
Statewide:
Dental Plans 1 – 6, Oregon Dental Services (ODS)
Dental Plans 7 – 8, Willamette Dental Group
Regional:
Dental Plans 7 – 8, Kaiser Permanente will offer dental coverage to those who are in the Kaiser service area and select Kaiser medical coverage.
I’ve heard that districts can expect the rates for the new OEBB medical plans to be 15 to 16 percent higher than the rates for plans offered to districts today, including up to four percent to cover administrative costs and recovery of start-up costs.
OEBB is not able to provide expected rates for the OEBB benefit plans at this time. While we understand trends for increases range from 12 percent to 15 percent in Oregon and nationally, we won’t know how that applies to the OEBB rates until we have selected the carrier(s) for the benefit plans and completed final rate negotiations.
The Board retained an actuarial firm to assist OEBB in determining healthcare cost trends as part of the evaluation of the request for proposal process. The apparent successful bidder(s) for the coverages will be named at the April 24, 2008, Board meeting. This will allow OEBB to move into the final negotiation process that includes setting the rates for the 2008-09 plan year.
The legislation creating and governing OEBB provides that OEBB can add an administrative fee of up to 2 percent to cover operational costs. It also requires that OEBB repay the General Fund used to cover costs associated with getting the benefits program up and running using the administrative fee. However, even when collecting funds to repay the start-up money, this fee cannot exceed two percent. Any operational or start-up costs associated with OEBB will be included in the administrative fee.
I have heard that district employees will lose their dental coverage when they move to OEBB. Is this correct?
No. When an employee group or district moves to OEBB, they will have the option of choosing between eight dental plans that include six fee for service and two DHMOs. Each employee group can select up to three options to offer to members and each group may select an orthodontia option to be paired with the dental plans offered. An orthodontia offering must be included in all dental options or it must be omitted from all dental plan options.
The ODS fee for service dental plans are available with annual maximum benefit amounts ranging from $1,000 to $2,200 and deductibles at zero, $25 and $50. All plans cover preventive services, restorative services, major services and prosthodontics. The DHMO plans have no deductibles or annual maximums.
What is the Oregon Educators Benefit Board?
The Oregon Educators Benefit Board administers the newly created statewide insurance pool for employees and eligible retirees of Oregon school districts and education service districts.
The Board was created when the 2007 Legislature passed Senate Bill 426. The OEBB will provide oversight and management of the insurance pool, design the benefit plans and contract with insurance carriers to deliver benefits to school district employees beginning October 1, 2008.
Why was the Board created?
The Board was created to offer school district and education service district employees and their dependents high-quality health, dental and other benefit plans at an affordable cost.
The intent of the bill was to put more money directly in the Oregon’s classrooms by saving school districts money on health insurance. Savings is expected because the size of the pool will provide more buying power and will reduce administrative costs associated with duplicating services for separate group administrators.
Studies by several groups throughout the past decade indicate that by pooling insurance, potential savings can add up to millions of dollars annually, but only time will tell how much is actually saved through the pool.
Additionally, with the creation of the OEBB, the rate of medical inflation affecting school districts is expected to slow because the Board will be better equipped to design and deliver a plan it sees as most beneficial to its members -- like proactive and preventive care, evidence-based health coverage, and providing members with increased awareness and education of health related topics.
Who makes up the Board?
The Board is made up of 10 members, all appointed by the Governor. Two members represent district boards; two members represent district management; two members represent non-management district employees from the largest labor union; one member represents non-management district employees from the second-largest labor union; one member represents non-management district employees not represented by labor organizations; and two members have expertise in health policy or risk management.
Board members serve four-year terms.
Additionally, an administrative staff manages the daily operations of the OEBB carrying out the responsibilities and tasks in support of the Board.
Since the bill’s passing, the 10 members of the Board have assembled. The first “informational” meeting was June 22, 2007 in Salem. The Board became an official, acting body on July 2, 2007, and has met twice a month since then.
Who managed the benefits plans prior to the creation of the OEBB?
Oregon’s school employees currently receive medical benefits primarily through one of three health insurance organizations: the Oregon Education Association (OEA) Choice Trust, the Oregon School Boards Association (OSBA) Health Trust and the Oregon State Education Association (OSEA).
Some school districts contract directly with insurance companies, while other are self-insured or offer coverage to their employees through individual health trusts.
How many people will the OEBB serve?
It is projected that about 165,000 district employees and their dependents will receive medical benefits through the OEBB once all districts are enrolled in October 2010.
What is the OEBB’s purpose? What are its duties and what types of benefit plans will the OEBB provide for my family and me?
Eventually the OEBB will provide a full line of high-quality benefits for you and your family. Benefits will include health, dental, life, disability, vision and long-term care insurance.
The OEBB will design a benefits program that will provide choices for its members, Oregon school districts and education service districts. In carrying out this task, the Board will identify and select insurance carriers to provide benefit plans and determine enrollment and participation requirements.
When the OEBB begins to offer plans on October 1, 2008, those plans must be comparable in design and cost to the benefit plans being provided to or by the districts prior to purchasing benefits through OEBB plans. The Board is in the process of defining what “comparable in design and cost” means. Several workgroups have been created – one of which will be identifying the benefit plan designs and preparing cost models for the Board to consider when defining comparability. This definition must be made before the Board can release Requests for Proposals for insurance carriers to submit bids for being allowed to provide coverage to OEBB members. The Board anticipates releasing the RFPs the first week in January 2008. To meet this timeline, plan design decisions will need to be made by late November or early December 2007.
What criteria will the OEBB use to choose benefits plans carriers?
The OEBB will contract plans that are designed to meet the needs and provide for the welfare of eligible employees and districts. The OEBB will consider the following: providing employees with choices among high-quality plans; encouraging competition in the marketplace; plan performance; quality of customer service; creativity and innovation; plan benefits as part of total compensation; improvement of employee health and district flexibility in plan design.
What advantages are there to “pooled” purchasing of health care benefits?
There are several advantages to creating a pooled plan of providing health care to employees of Oregon’s school districts including creating accountability and transparency, and allowing for greater purchasing power of the plans from carriers.
When will employees -- including non-represented employees such as administrators, supervisors and confidential staff --of school districts and education service districts be required to join the OEBB?
Employees of school districts and education service districts are required to join the OEBB based on when their collective bargaining agreements expire. However, the Board must begin offering benefit plans effective on October 1, 2008. With that in mind, the Board has filed temporary administrative rules establishing guidelines for the future phase-in of school and education service district employees, and taken the action necessary to allow community college district and charter school employees to move to benefit programs offered by the OEBB.
- Employee groups of any school or education service district (including those who are self-insured), community college district or charter school may elect to participate in benefit plans provided by the Board beginning October 1, 2008, October 1, 2009, or October 1, 2010 without having to meet phase-in requirements. Employee groups electing to participate in benefit plans provided by the OEBB must provide written notice to the Board that they wish to enroll in the plans no later than May 31 (June 30 for 2008) of the year in which they plan to participate beginning on the following October 1. Once an employee group elects to participate in the benefit plans offered by the OEBB, it cannot return to benefit plans provided or administered by any entity other than the Board.
- Employees of a school or education service district represented by a collective bargaining agreement that ends, July 1, 2007, through June 30, 2008, must participate in the benefit plans provided by the OEBB beginning October 1, 2008.
- Employees of a school or education service district represented by a collective bargaining agreement that ends, July 1, 2008, through June 30, 2009, must participate in benefit plans provided by the OEBB beginning October 1, 2009.
- Employees of a school or education service district represented by a collective bargaining agreement that ends on or after July 1, 2009, must participate in benefit plans provided by the OEBB beginning October 1, 2010.
- Employees of a school or education service district not represented by a collective bargaining agreement must participate in benefit plans provided by the OEBB when the represented employees at the same school district or education service district begin participating in the OEBB plans according to timelines listed above. If there is more than one collective bargaining agreement contract in existence at that school district or education service district, the earliest collective bargaining agreement to expire must be applied.
Who is required to participate in the OEBB?
All school and education service districts are required to purchase their benefit plans through the OEBB unless they were self-insured or had an independent health trust in place on December 31, 2006.
Are there any exceptions to participation in the OEBB?
There are a few exceptions to participation in the OEBB. School and education service districts that are self-insured or provide benefits through an independent health trust that was functioning as of December 31, 2006, are not required to move to the OEBB benefit plans. However, beginning October 1, 2010, if a self-insured district wants to continue providing benefit plans other than those offered by the OEBB, it must submit an application to be excluded from the Board’s plans.
- The submitted application must show that the premiums for the benefit plans provided or contracted for the district are equal to or less than the premiums for comparable benefit plans provided by the Board.
- Applications must be submitted to the Board no later than May 31, 2011 and each year that follows.
Who is eligible to enroll in OEBB plans?
For the most part, eligibility will remain the same as it is under current plans offered by school and education service districts. The Board will be reviewing eligibility requirements used by the current carriers, identified under current collective bargaining agreements and included in the legislation (SB 426) and preparing administrative rules outlining employee, retiree and dependent eligibility over the next two months. Temporary rules will be discussed and approved during public board meetings in late October or November to allow the definitions to be used during the Request for Proposals process that solicits bids from carriers interested in providing coverage to OEBB members beginning October 1, 2008. Before the temporary rules can be replaced by permanent rules, the Board will invite all interested parties to participate in the public hearing process. Notices of public meetings and public rulemaking hearings will be posted on the OEBB Web site.
Will there be any review or study of the effectiveness of the OEBB?
Senate Bill 426 also created a Task Force on Educator Health Benefits. The Task Force will consist of six members: one from the Senate, one from the House of Representatives, one who is a district employee represented by a labor organization, one who is a district management employee and two who are not OEBB participants and who have expertise in health insurance or employee benefits plan design or administration.
The Task Force is expected to review the benefit plans and administration provided by the OEBB to determine the cost savings created by the mandatory pool and submit a report to an interim committee on education or public employment no later than October 1, 2012.
When will I be able to begin enrolling for benefits?
The OEBB benefit plans will be available October 1, 2008. Your ability to enroll in the OEBB plans depends on which district you work in and which, if any, collective bargaining group you are in or have.
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