Benefits 101

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 choose from.

    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 greatly in:
    • 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 medical plans:
    • 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

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

    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.


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. 

  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.

  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.

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 are approximate)*

 

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-network providers

    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.

  • Pediatric dental benefits
    A healthy smile can help maintain overall health

    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 at a glance

    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 getting started?
    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 vision benefits

    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. VSP offers:
    • The best care
    • Low out-of-pocket costs
    • Hundreds of frame options from classics to designer brands


    How to use your VSP benefits

    • 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 vision perks

    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 of your eyes

    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 aid benefit.

    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 503-574-7500 or 800-878-4445 (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 our guide to preventive health care (PDF).
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