Member Benefit Basics | Providence Health Plans (2023)

Understanding your healthcare benefits doesn't have to give you a headache. We're here to help you put away that bottle of ibuprofen and start down a path with us as your true partner on your healthcare journey. We're simply a community of humans helping humans stay healthy.

If you're enrolled in a Providence Health Plan, whether through an individual and family plan, a Medicare Advantage plan, or through your employer — you can count on comprehensive coverage and genuine care.

Below you’ll find resources to help you understand your benefits and maximize your membership. Meeting your needs on your journey to achieving True Health starts here.

Benefit basics

  • What is health insurance?

    Health insurance is a contract between the person who buys health insurance (for example, an individual, employer, or association) and a health insurance company. You (and/or your employer) pay a premium— a specific amount of money— for your insurance coverage. In exchange, the health insurance plan pays all or a portion of the health care service cost. While no one plans on getting sick, it happens. Having health insurance helps pay for these costs and provides protection from very expensive medical services in the event care is needed.

  • Things to know about health insurance
    There are a lot of plans, providers, and coverage options to choosefrom.

    When you receive care from a provider, you may have to pay a copayment (a flat dollar amount) or a coinsurance (a percentage of the amount) for health care services (such as an office visit, lab work or an X-ray).


    You may have to meet a deductible each year before your health plan begins paying benefits.


    In-network providers have an agreement with the health plan to participate as a health care provider for a given plan. Plan benefits are typically better when services are rendered by an in-network provider.


    Plans typically have a calendar or plan year out-of-pocket maximum, which is the most youll pay for covered health services during the plan year.


    After you receive care, the provider will submit a claim for services. Your health plan will send payment to the provider and will send you an Explanation of Benefits, which shows how the claim was paid. Read more about this via the EOBs explained link below.

    Your provider sends you a bill that shows what your health insurance company paid and what you still owe for the care received. It’s your responsibility to pay the provider the remaining balance.


    Explanation of benefits (EOB) explained

  • Types of medical plans
    There are a number of different types of medical plans. They are similar in that they cover many of the same services. Yet, they can differ greatlyin:
    • How much you pay for coverage (i.e., the health insurance premium)
    • The amount you pay each year before the plan pays for covered services (i.e., the deductible)
    • Provider choice
    Here are 3 common types of medicalplans:
    • Health Maintenance Organization (HMO). Under an HMO, your health insurer gives you a list of primary care physicians (PCP) you can choose from. If the doctor you want to see is not part of the plan's network, you could see that doctor, but you may pay for the complete cost of care. Generally, your primary care provider also needs to refer you to a specialist if you want to see one.
    • Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO). A PPO plan provides more provider choice. You may go to any doctor you want, but visits are more affordable if you choose in-network providers. You do not need a referral to see a specialist.
    • High deductible plan + health savings account (HSA). Another health care option is a high-deductible health plan along with a health savings account (HSA). In exchange for having a higher deductible, you pay a lower monthly premium. After you sign up with a high-deductible plan, you're eligible to open an HSA. You'll get a debit card with your HSA. Any time you need to pay for qualified medical expenses (for instance copays, prescription drugs), use your debit card to pay for the cost of care. Any money left over in your account at the end of the year rolls over to the following year. Plus, HSAs have some tax advantages.

    Learn more about HSA plans


    Learn more about qualified medical expenses

    (Video) Health Plan Basics: Benefits

  • Health insurance words & phrases
    Like any industry, health insurance has its ownterminology

    Before you receive care, get to know what an insurance word or phrase means. The more you know, the more you can make the most of your benefits and your health.


    Glossary of health care terms

  • Health accounts can help you save
    There are several different types of integrated accounts including health savings accounts (HSAs), health reimbursement arrangements (HRAs), and flexible spending accounts(FSAs).

    Your employer may have selected a healthcare account plan.


    Whichever type is available to you, you can be assured that Providence Health Plan, along with our partner HealthEquity, is committed to ensuring that your enrollment, billing and claims are seamless. Explore the links below to see if one of these health accounts is right for you.


    • What is a Health Savings Account (HSA)?
    • What is a Health Reimbursement Arrangement (HRA)?
    • What is a Flexible Spending Account (FSA)?
    • Examples of qualified medical expenses
    • Examples of non-qualified medical expenses

Understand how your health plan and providers work together

The following example provides a general overview of what to expect when your use your health plan benefits:

You need to go to the doctor for an ongoing cough. You want to use your benefits wisely, so you decide to access care from an in-network provider.

  1. Finding a provider

    Find an in-network provider by searching the provider directory.

  2. Scheduling an appointment

    Use your myProvidence account via myChart or call the office to arrange your visit.

    (Video) High-Deductible Health Plans, Explained

  3. Going to see your doctor

    Your provider finds that you have an infection. She prescribes an antibiotic to treat your infection.

  4. Picking up your prescription

    You fill your prescription by choosing an in-network pharmacy which you found by searching the Provider & Pharmacy Directory.

  5. What your provider pays

    The health plan pays its share of amount(s) owed to your provider and sends you an Explanation of Benefits (EOB) explaining how the claim was paid.

    EOBs explained

  6. What you pay

    You will receive a bill from your provider for any amount you owe. That amount will be paid directly to the provider or through Providence bill pay for Providence providers.

    (Video) Health Insurance 101: The Basics (Health Insurance 1/3)

What if you didnt have health insurance?

Seeking medical treatment for illnesses or accidents would be very expensive without health insurance. Health insurance offsets the cost of doctor bills, surgery, hospital, laboratory and X-ray fees, and pharmacy costs.

Take a look at the following two examples that compare costs without insurance to costs with insurance in a plan that has a preferred provider network:

Example 1: Sample healthcare cost for a sports injury (costs areapproximate)*

Service

Cost without insurance

Cost with insurance

Office visit $190 $20 copay
CT scan $1500 $300 (you pay 20% of the cost)
Emergency room $500 $250
Radiologist $300 $60 (you pay 20% of the cost)
Lab work $160 $32 (you pay 20% of the cost)
X-ray $150 $30 (you pay 20% of the cost)
Urgent care $190 $38 (you pay 20% of the cost)

Total cost:

$2,890

$730

*This example assumes the calendar year deductible has been met and that care is received from an in-network provider. Your insurance provider pays the in-network provider the balance, up to the contracted rate.

Example 2: Sample healthcare cost for strep throat*

Service

Cost without insurance

Cost with insurance

Office visit $190 $20 copay
Prescription for an antibiotic $50 $10 copay

Total cost:

$240

$30

*This example assumes a calendar year deductible need not be met for the plan to pay benefits, care received was from an in-network provider and a generic prescription drug was purchased. Providence Health Plan pays the in-network provider the balance, up to the contracted rate.

More information about your benefits

  • Alternative care
    Your member materials indicate plan coverage and benefits, including any related to alternative care coverage. Log in to myProvidence to access plan materials. Get discounts on acupuncture, chiropractic care, massage therapy, and dietitian services.

    Plan benefits and in-networkproviders

    An alternative care provider is a naturopath, chiropractor, acupuncturist, or massage therapist who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness, and who provides services within the scope of that license.


    Plan benefits for alternative care services and provider networks vary. Please talk with your benefit administrator or refer to your member materials for information about your specific plan benefits. To locate an in-network provider, please refer to the Provider Directory.


    We’re here to help. Contact Providence Health Plan customer service at 800-878-4445 for assistance, including those related to alternative care eligibility and benefits.

    (Video) Health Insurance Coverage 101 - the Basics Explained in Two Minutes

  • Pediatric dental benefits
    A healthy smile can help maintain overallhealth

    Tooth decay is the leading childhood disease in America; yet, it’s completely preventable. A quality dental plan can mean better health, fewer sick days, and a better smile. Make the most of your child’s health with Providence pediatric dental plan benefits.


    Pediatric dental benefits are included in many Providence health plans. To see if your medical plan includes pediatric dental benefits, check your member materials by logging into myProvidence and selecting the "Member Material" link under "My Health Plan."

    Dental benefits ataglance

    If your health plan includes pediatric dental coverage, your enrolled dependents up to age 19 have access to:


    • Preventive services (e.g., routine exams, bitewing X-rays, and cleanings) that are covered in full when services are received from an in-network dentist
    • More than 210,000 in-network dentists across the nation
    • No waiting periods
    Need help gettingstarted?
    1. Review your member material, including your benefit summary, to confirm dental coverage and specific dental benefits. You’ll find your summary in our secure member website, myProvidence.
    2. Visit the provider directory to locate an in-network dentist. On the right side of the provider directory screen, select “Routine Dental Services” from the Provider Type drop down field. Select the orange “Go” button.
    3. Schedule an appointment with an in-network dentist to make the most of your dental benefits.
  • Vision benefits
    Your health plan coverage may include visionbenefits

    If you have vision coverage, your member materials will indicate plan coverage and benefits. To view your health plan benefits, log in to myProvidence.


    Providence Health Plan partners with VSP Vision Care, the only national not-for-profit vision company. VSPoffers:
    • The best care
    • Low out-of-pocket costs
    • Hundreds of frame options from classics to designer brands
    How to use your VSPbenefits

    • Review your member material, including your benefit summary through myProvidence.
    • Use the provider directory to locate an in-network provider. When searching for a provider, choose "routine vision services" from the Provider Type drop-down to the right of your search results.
    • Schedule an appointment with your VSP provider. Tell the scheduler that you have VSP.

    Tip: When you access care from a VSP provider, you’ll need your 17-digit VSP member ID number. Your VSP member ID is your Providence Health Plan member ID number* plus your Providence Health Plan Group number. Both numbers are located on the front of your member ID card. Be sure to provide all 17 digits when contacting VSP regarding eligibility, services, benefits or claims.


    * Each plan participant has a unique member ID number. Be sure to reference or provide the card of the individual who is receiving services.

    Other visionperks

    As a Providence Health Plan member, you have access to discounts through Northwest Vision Associates and Visionworks. These discounts are available to you regardless of your medical plan selection. To find out more, visit:


    Tips to take care ofyoureyes

    There are things you can do to keep your eyes healthy. In addition to regular vision checkups,see what you can do.

    Plan benefits and in-network providers

    Vision benefits and provider networks vary by plan. Please talk with your benefit administrator or refer to your member materials for information about your specific plan benefits. Your benefit summary includes details regarding covered benefits, in-network providers and copays, coinsurance and deductibles. In the event that there is a discrepancy between information on this page and your plan contracts, the plan contracts govern.

  • Hearing aid benefits
    Your health plan coverage may include a hearing aidbenefit.

    Hearing aids are considered medical equipment and are subject to plan requirements such as medical necessity, deductible(s), and network requirements.


    Information about medical necessity, network requirements, and your plan coverage for medical equipment is included in your member materials. Your member materials are available online when you create a free myProvidence account.


    Providence Health Plan has partnered with TruHearing to provide members with affordable options for hearing aids.


    To learn more about coverage for hearing aids and to locate a TruHearing provider, contact Providence Health Plan customer service at 503-574-7500or800-878-4445 (TTY: 711).

  • Preventive healthcare
    Why is preventive care so important?
    • Preventive care allows you to detect potential health concerns early before a more serious health issue shows up.
    • It’s much easier — and far less expensive — to address health problems now rather than to try to cure them once they occur.
    • Learn more about how to make the most out or your preventive care options in ourguide to preventive health care(PDF).
Need help?

FAQs

How do I write a summary of benefits? ›

Where can I find a Summary of Benefits and Coverage? You'll find a link to the SBC on each plan page when you preview plans and prices before logging in, and when you've finished your application and are comparing plans. You can ask for a copy from your insurance company or group health plan any time.

What is the purpose of the summary of benefits and coverage SBC )? ›

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you.

Is Providence an HMO or PPO? ›

Providence Access+ HMO plan

Have access to one of the largest provider networks in California, with more than 13,000 primary care physicians (PCPs), 350 hospitals, and 48,000 specialists.

Is Providence in Cigna network? ›

Providence Health Plan partners with Cigna.

What are the 3 types of benefits? ›

There are three main types of employee benefits:

Employee benefits that are required by law. Employee benefits that aren't required by law but considered an industry standard. Employee benefits that are offered as an added perk or fringe benefit.

How do you explain assignment of benefits? ›

What is an Assignment of Benefits? An AOB is an agreement that transfers the insurance claims rights or benefits of the policy to a third party. An AOB gives the third party authority to file a claim, make repair decisions, and collect insurance payments without the involvement of the homeowner.

What is normally included in the benefits package? ›

A benefit package covers the full scope of services, pay, insurance, vacation time and other perks available to an employee from his employer.

What is not included in the benefit summary? ›

Additionally, some health insurance companies don't count all copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.

What is the difference between a HMO and PPO plan? ›

Choosing between an HMO or a PPO health plan doesn't have to be complicated. The main differences between the two are the size of the health care provider network, the flexibility of coverage or payment assistance for doctors in-network vs out-of-network, and the monthly payment.

Is Providence part of Anthem Blue Cross? ›

Anthem Blue Cross of California is expanding their Vivity Network on January 1, 2021 to include all Providence and St.

Is Kaiser merging with Providence? ›

Mary partnership. California Attorney General Rob Bonta approved a new partnership between Oakland-based Kaiser and Apple Valley-based Providence St.

Is Cigna a Chinese company? ›

Cigna is an American multinational managed healthcare and insurance company based in Bloomfield, Connecticut.

Is Cigna accepted everywhere? ›

Cigna offers a broad network of health care professionals and facilities throughout California.

Are Anthem and Cigna the same company? ›

Shortly after Aetna and Humana announced their planned merger, Anthem and Cigna followed suit. On Friday, July 24, Anthem made public its definitive agreement to acquire Cigna Corporation for a total valued transaction of $54.2 billion. Currently, Anthem is the nation's second largest health insurer.

What are the three most important benefits? ›

Most Desirable Benefits According to Employees

If you want your benefits package to remain competitive, you'll want to offer health insurance, some disability and life insurance, and probably a retirement plan, such as a 401(k).

What are the 4 types of benefits? ›

There are four major types of employee benefits many employers offer: medical insurance, life insurance, disability insurance, and retirement plans.

What are the top 5 benefits? ›

The Top 5 Employee Benefits for 2022
  • In 2022, businesses are offering employee benefits designed to attract, retain, and support their workers. ...
  • Mental health coverage. ...
  • Emergency savings accounts. ...
  • Pet insurance. ...
  • Employer-covered healthcare. ...
  • More paid-time-off. ...
  • Contact SecureSave to talk about one of the best employee benefits.
9 Mar 2022

What considered good benefits? ›

Health insurance, flexible hours, and vacation time. In today's hiring market, a generous benefits package is essential for attracting and retaining top talent.

What kind of benefits should I ask for? ›

Consider hiring bonuses, vacation time, retirement plans, sick leave, insurance, and other company benefits as open for negotiation as well. If you are planning to go back to school, tuition reimbursement may be just as important as health insurance.

Who receives the explanation of benefits? ›

Usually, the insurer sends the EOB to the primary person on the health plan. If an employer provides the insurance, the employee usually receives the EOB, including EOBs for a spouse and dependents on the plan.

What does assignment of benefits mean health insurance? ›

An assignment of benefits is when a patient signs paperwork requiring his health insurance provider to pay his physician or hospital directly.

Who receives the explanation of benefits report? ›

Around the time you receive your patient billing statement, you will also receive an explanation of benefits (EOB) from your insurance provider. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received.

What does a good benefits package look like? ›

While this can differ depending on who you ask, the standard in most industries consists of health insurance, dental insurance, flexible spending accounts, retirement savings plans, vacation time, and additional paid time off for events like family medical leave, maternity leave, and sabbaticals.

How much does a benefits package add to your salary? ›

The average benefits package is over 30% of an employee's compensation.

What is a benefit statement example? ›

Let's take a look at some examples of a Benefit Statement: Patagonia's Benefit Statement is to “build the best product, cause no unnecessary harm, use business to inspire and implement solutions to the environmental crisis.”

How do I read my health benefits? ›

8 Tips for Reading Your Health Insurance Policy
  1. Determine How Much You Will have to Pay. ...
  2. Understand the Type of Health Insurance Plan You Have. ...
  3. Make Sure Your Doctor and Hospital Are In Network. ...
  4. Get to Know Your Benefits Inside and Out. ...
  5. Take Note of the Health Insurance Policy's Coverage Dates.
7 Feb 2017

What does benefit not covered mean? ›

Both private and public health insurance plans can deny coverage for a service on the grounds that it is “not a covered benefit.” This type of denial means that, according to your health insurance plan, your member benefits do not include the requested service and you are responsible to pay for the service.

Why do doctors not like HMO? ›

That's the problem with HMO's. To quote a Survivor of two primary breast cancers: "The disadvantage of an HMO is that the patients give up control of their own health care to medical groups that vary in quality and abilities and whose primary concern is their profit rather than the patient's health.

Why would a person choose a PPO over an HMO? ›

PPOs Usually Win on Choice and Flexibility

If flexibility and choice are important to you, a PPO plan could be the better choice. Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.

What are the 4 basic types of insurance? ›

Four types of insurance that most financial experts recommend include life, health, auto, and long-term disability.

Is Anthem Blue Cross changing their name? ›

The new name, pending shareholder approval, will be Elevance Health. We will continue to do business as Anthem Blue Cross and Blue Shield. Why the change? advance health beyond healthcare for our customers, their families, and our communities.

Is there another name for Anthem Blue Cross? ›

Enrollment in Anthem Blue Cross depends on contract renewal. Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.

Is Anthem Blue the same as Blue Shield? ›

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company an independent licensee of the Blue Cross Blue Shield Association.

Who did Kaiser Permanente buy out? ›

Oakland, Calif. -based Kaiser Permanente completed its $1.8 billion acquisition of Seattle-based health plan Group Health Cooperative. The integrated healthcare system now provides coverage to more than 11.3 million members in eight states and residents in Washington, D.C.

Who is Kaiser Permanente main competitors? ›

Kaiser Permanente's competitors and similar companies include Highmark, Harvard Pilgrim Health Care, Cleveland Clinic and Mayo Clinic. Kaiser Permanente (also known as Kaiser Foundation Health Plan) is a non-profit organization providing healthcare plans. Highmark is a nonprofit health and wellness system.

What company owns Kaiser? ›

Kaiser. Thus, the organization currently known as Kaiser Permanente was born. We are still based on the close cooperation between 3 entities: the nonprofits Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, and the Permanente Medical Groups.

Who is Cigna's biggest competitor? ›

Cigna Corporation competitors include UnitedHealth Group, CVS Health and Aetna. Cigna Corporation ranks 1st in CEO Score on Comparably vs its competitors.

What American companies are controlled by China? ›

  • General Electric (GE) ...
  • AMC Theatres. ...
  • Smithfield Foods. ...
  • Legendary Entertainment Group. ...
  • The Waldorf-Astoria. ...
  • Strategic Hotels & Resorts. ...
  • Riot Games. ...
  • Sheraton Universal Hotel, Marriott Downtown Los Angeles.

Is Cigna and UnitedHealthcare the same? ›

The companies stack up well against each other in terms of Medicare Part D plans, but UnitedHealthcare offers more Medigap plans and sells Medicare Advantage plans in more states than Cigna. Cigna does have a leg up in terms of quality though, with its perfect 5-star rating for 2021.

What Cigna does not cover? ›

Non-medical counseling or ancillary services including, but not limited to Custodial Services, education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return-to-work services, work hardening programs, driving safety, ...

What insurance is accepted in all 50 states? ›

Most Blue Cross Blue Shield members can rest easy since Blue Cross Blue Shield coverage opens doors in all 50 states and is accepted by over 90 percent of doctors and specialists. And if your extended travel plans take you abroad, you can ensure you have access to quality care through GeoBlue.

Will Cigna approve an MRI? ›

Your doctor contacts us to request approval for an MRI, CT, or PET scan. While reviewing the request, we also check to see where the doctor ordered the services to be performed. We check to see if another in-network, local facility offers the same services at a lower cost.

Who is better Anthem or Cigna? ›

See how Cigna and Anthem ranked among the industry ratings.
...
What is Cigna and Anthem Insurance Rating?
ComparisonCignaAnthem
Medicare Star Rating3.5 stars (out of 5)
BBB RatingA+A+
NAIC Complaint Index1.15% for individual health0.30% for individual health insurance
Market Share Percentage6.3%
2 more rows

Is Cigna being bought out? ›

Group Life and Disability Business Rebranded New York Life Group Benefit Solutions. NEW YORK, December 31, 2020 - New York Life, America's largest mutual life insurer1, today announced the completion of the company's acquisition of Cigna's group life, accident, and disability insurance business.

Is Cigna the same as Aetna? ›

One distinction is that Aetna is a U.S.-focused company, offering medical insurance through employers and on the individual market. Cigna is a global provider of health insurance for employers in more than 30 countries, according to its website.

What is a benefit summary? ›

Summary of Benefits & Coverage: Overview

The SBC is a snapshot of a health plan's costs, benefits, covered health care services, and other features that are important to consumers.

What is an example of a benefit statement? ›

Let's take a look at some examples of a Benefit Statement: Patagonia's Benefit Statement is to “build the best product, cause no unnecessary harm, use business to inspire and implement solutions to the environmental crisis.”

How do you explain Explanation of Benefits? ›

An Explanation of Benefits (EOB) is a statement that your insurance company sends that summarizes the costs of health care services you received. An EOB shows how much your health care provider is charging your insurance company and how much you may be responsible for paying. This is not a bill.

What should I write in benefits? ›

Top 5 keys for crafting a benefit statement
  1. Keep it short and to the point. ...
  2. Make your benefits measurable. ...
  3. Describe an ideal future state, but be realistic. ...
  4. Hone in on what you're really selling. ...
  5. Emphasize your competitive advantages.

What is a proof of benefit? ›

The Proof of benefits letter is available for individuals who are in receipt of Employment and Support Allowance, Job Seekers Allowance, Income Support, Incapacity Benefit and Universal Credit. The Proof of benefits letter can provide verification of long-term unemployed (LTU).

What are common benefits? ›

These benefits typically include medical insurance, dental and vision coverage, life insurance and retirement planning, but there can be many more types of benefits and perks that employers choose to provide to their teams.

How do you explain employee benefits? ›

Employee benefits are any forms of perks or compensation that are provided to employees in addition to their base salaries and wages. A complete employee benefits package may include a health insurance plan, life insurance, paid time off (PTO), profit sharing, retirement benefits, and more.

What are basic benefits package? ›

Employee benefits packages include non-salary compensation like health care coverage, retirement benefits, and paid time off. Federal law requires employers to offer benefits like COBRA, FMLA, and minimum wage standards; many states mandate further coverage including disability, workers comp, and additional leave.

What benefits are most valued? ›

The most sought-after employee benefits are:
  • Paid time off. ...
  • Flexible hours. ...
  • Paid family leave. ...
  • Four-day work week. ...
  • Free food in the office. ...
  • Student loan assistance. ...
  • Pet insurance/pet friendly offices. ...
  • Fitness perks. Gyms and yoga studios have certainly struggled during the pandemic.

What does benefit amount mean? ›

Benefit Amount means the insurance benefits provided in the policy and is the amount of insurance issued as shown on the Schedule.

What does Explanation of Benefits mean in insurance? ›

An explanation of benefits (EOB) is the insurance company's written explanation regarding a claim, showing what they paid and what the patient must pay. The document is sometimes accompanied by a benefits check, but it's more typical for the insurer to send payment directly to the medical provider.

Who usually receives Explanation of Benefits? ›

Usually, the insurer sends the EOB to the primary person on the health plan. If an employer provides the insurance, the employee usually receives the EOB, including EOBs for a spouse and dependents on the plan.

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