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III. Health Insurance
1. Medical plans offered by Fermilab
a) Visitors at Fermilab
b) Fermilab employees
2. HMO, PPO and POS (Health insurance plans for Fermilab employees)
a) Health Maintenance Organization (HMO)
b) Preferred Provider Organization (PPO)
c) Point-of Service (POS)
d) Dental Care
3. How to choose a doctor
4. Glossary of terms you might need if dealing with health insurance questions
Medical insurance is an important part of working at Fermilab, and all employees and visitors are required to have medical insurance. The medical insurance options available through Fermilab are under frequent review, are subject to change, and may not be in force on the day you arrive. Fermilab makes no guarantee that the options described below will be the same when you arrive here.
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| 1. |
Medical plans offered by Fermilab
a) Visitors at Fermilab
If you work at Fermilab, but do not receive any salary by Fermilab, you are considered a visitor. Visitors are not eligible to the medical plans offered by Fermilab to its employees. Yet, health insurance is mandatory in order to get a Fermilab visitor ID. You must either be insured through the organization that sent you to work at Fermilab (a U.S. university, for example, cooperating with Fermilab's experiments), buy your own insurance package in your home country with international coverage, or buy your own insurance package in the U.S. If you will stay in the U.S. in J-1 visa status, you need to make sure that the insurance you purchase from your home country meets the J-1 visa insurance requirements.
The Fermilab User's Center offers special packages designed for short-term visitors. The period of coverage can last from a minimum of 15 days up to a maximum of 18 consecutive months. The insurance company Gateway determines its rates mostly by age. Example: As a thirty to thirty-nine year old male, you currently would pay $64 per month for an insurance with minimum medical benefits, paying more if you need to insure family members as well. This health insurance meets the J-1 visa health insurance requirements.
Under certain circumstances you might be eligible for a Preferred Provider Organization (PPO) plan provided by Fermilab, that may give you better medical coverage for $187 per month (cost is subject to change).
You should talk to Dianne Snyder or Barbara Book in the User's Office to figure out the best way for you to get appropriate health insurance. Remember: You have to be insured!
b. Fermilab Employees
Employees at Fermilab are required to have health insurance. Like many large employers in the U.S., Fermilab offers several health insurance plans. The monthly rates for health insurance paid by employees are low, because Fermilab pays for a large fraction of each employee's health insurance premium. New employees must select a medical plan on the first day of employment. Fermilab's Human Resources Department will provide you with more information once an offer is made.
You can choose between three different medical plans (BlueCross/BlueShield/HMO, Cigna/PPO and Cigna/POS) and two different dental plans (Cigna/HMO and Cigna/PPO). BlueCross/BlueShield and Cigna are companies or federations of independent health care providers, that offer group insurance plans. HMO, PPO, and POS stand for the type of insurance plan offered. The differences, advantages and disadvantages are explained in the following.
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| 2. |
HMO, PPO and POS (Health insurance plans for Fermilab employees)
While currently the monthly costs for all medical plans provided for Fermilab employees are the same (please find the exact rates in the benefits package that was sent to you together with the offer letter), every plan has its own features and benefits. Therefore, making your choice is a question of selecting your health insurance to your personal needs and not a question of good or bad, right or wrong. You should determine your healthcare needs, based on
- your personal health condition,
- your need for alternative care, such as treatment by a chiropractor,
- flexibility regarding choice of physicians,
- possibility to obtain an immediate second opinion.
Compare the different services before you select one of the healthcare plans. The Fermilab benefits department has listed the most often required medical services in a summary table, that you can find in the back of this chapter.
Keep in mind that you can (only) switch your insurance every year in September during the open enrollment period.
a. Health Maintenance Organization (HMO)
An HMO covers most of the basic healthcare needs with very low out-of-pocket costs for the patient. Members have to choose a primary care physician (PCP), who becomes the personal doctor. Women are usually allowed to choose an Obstetrics/Gynecologist (OB/GYN) in addition to their PCP. No matter what health problem you encounter, it is required that you always call your PCP first. This includes routine medical care, such as annual physical exams, immunizations and other health concerns. Even in case of an emergency, you have to contact your PCP. Only in life-threatening emergencies will first aid without prior approval from your PCP be covered under the health plan.
To see a specialist, receive special treatments, or get lab work done, the PCP has to issue a referral that needs to be approved by the HMO. This process can take a few days. The PCP determines whether or not the services of a specialist are needed. Thus, the HMO healthcare plan leaves no freedom of choice of a physician, but covers most treatments with very few exclusions, no deductibles, and small co-payments.
b. Preferred Provider Organization (PPO)
A PPO offers a nationwide network of physicians that provides full health care services without choosing a PCP. Members may go to any physician of the network, even a specialist, at any time; referrals are not necessary. However, you often are subject to paying large parts of the cost. If you seek healthcare outside the network, your out-of-pocket costs are even higher.
A co-payment for each visit at a physician is required - regardless if he or she operates in or out of the network. The PPO coverage is subject to an annual deductible. You must have paid a significant amount per year yourself before PPO starts covering some or all of the remaining costs.
c. Point-of-Service (POS)
Just like an HMO, a POS requires that members choose a physician as PCP. Each time you need care you can see your PCP and keep your out-of-pocket costs at their lowest and coverage levels at their highest. In case you see another doctor without first getting a referral from your PCP, the costs will be higher and the coverage lower. For visits at the PCP no deductibles apply. If you receive care from an in-network physician other than your PCP or an out-network physician, the out-of-pocket costs are subject to an annual deductible of $300 per person. After having paid this amount you still have to pay 30% of the costs of out-of-network care, with an annual out-of-pocket limit of $3,000 per person.
POS and HMO are somewhat similar if you limit your medical care to in-network physicians. POS, however, gives you the freedom to see doctors other than your PCP without referral, and still be partly covered by your insurance.
d. Dental Care
The same differences between HMO and PPO as described above apply to the Dental Care plan offered by Fermilab. With HMO, you select one dentist as your personal dentist. With PPO, you can visit any dentist you want, but depending on whether he or she is part of the PPO network and whether you have met the deductible, the reimbursement for your dental care expenses will be higher or lower.
The monthly costs for the two dental plans differ. Please find the exact rates in the benefits package that was sent to you with the offer letter.
It seems that for people who are going to stay in the U.S. only for a few years, are in good health and do not need to see a doctor on a regular basis (no pre-existing health problem), HMO is a sufficient and the least expensive choice. Everybody who needs more flexibility in choosing a doctor, wants to get an immediate second opinion, or who plans to stay in the U.S. for a longer period of time, may want to think about selecting PPO or POS.
Note: Once you have joined a health care plan, you are allowed to switch from one plan to another only once a year in early fall (usually the first two weeks of September) during open enrollment.
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| 3. |
How to choose a doctor
If you have to select a doctor as your PCP, you may wonder how you are supposed to make this very important decision without knowing any doctor in the U.S. Of course, referrals of friends, neighbors and colleagues are always helpful. You can request a directory from the Employment Office or Benefits Office listing all participating doctors of which you can choose the one you wish. In the U.S. most doctors are operating as part of a medical groups or clinic, which in turn are cooperating with a major medical facility, mostly hospitals.
One way to make a selection is to find out which hospital or major medical facility is closest to your home or work. Usually these facilities have referral services, where you can get profiles and backgrounds of doctors that may fit your needs and are currently accepting new patients. You can find the hospitals that cooperate with your health plan also in the provider directory mentioned above. Look up the medical groups cooperating with this hospital and choose one of the doctors participating in one of the associations. The insurance company may even provide a ranking of all practices, which should make your choice a little easier.
You may want to consider choosing a physician who practices together with other doctors in the same office facility. You still have to choose one PCP, but you will be able to see another doctor of the same facility if your PCP is not available.
It is possible to change your PCP. You have to make two phone calls: 1) call your HMO or POS to inform them that you want to change your PCP. They will let you know the effective date of your change. If you call before the 21st of a month, you should be able to see the new doctor by the first of the following month. In the meantime only visits at your original PCP are covered. 2) call the group you have chosen to inform them that you have chosen Dr. X as your PCP. Be aware that some physicians do not accept new patients.
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4. Glossary of terms you might need if dealing with health insurance questions
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| Benefits |
The portion of the costs of covered services paid by a health plan. For example, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit." |
| Board-certified physician |
Any physician who has completed medical school, internship and residency in his or her chosen specialty and has successfully completed an examination conducted by a group (or board) of peers. |
| Coinsurance |
A traditional method of paying for covered health services in which a portion of covered expenses are shared by the health plan and the covered individual. It's a defined percentage of the covered charges for services rendered. For instance, a health plan may pay 80% of the reasonable and customary cost of covered services, and the covered individual pays 20%. |
| Co-payment (co-pay) |
The fee a patient pays at the time of service. Co-payments are predetermined fees for physician office visits and prescriptions. |
| Coverage |
The benefits that are provided according to the terms of a patient's specific health benefits plan. |
| Deductible |
The money an individual or family must pay from their own funds toward covered medical expenses before the plan pays, usually based on a calendar year. For example, if a plan has a $100 deductible, the deductible is met once the first $100 of the covered medical expenses for that year have been paid by the individual. After that, the health plan begins to pay toward the cost of covered health care services at the plan's coinsurance level (see Coinsurance). |
| Dependent |
A person eligible for coverage under an employee benefits plan because of that person's relationship to an employee. Married spouses, natural children and adopted children are often eligible for dependent coverage. |
| HMO |
Health Maintenance Organization. An organization that arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care. |
| Health plan |
A term that has different meanings depending upon the context. "Health plan" can be used to refer to an HMO, a health benefits plan offered by an employer to its employees, or a health benefits plan offered to employers by an insurer or third party administrator. |
| Inpatient care |
Care given to a patient admitted to a hospital, extended care facility or nursing home. |
| Medicare |
Title XVIII of the Social Security Act provides payment for health services to the eligible population aged 65 and over regardless of income, as well as certain disabled persons. |
| Network |
A group of health care providers under contract with a managed care company within a specific geographic area. |
| Open enrollment |
A period when eligible persons can enroll in or switch to a new health benefits plan. |
| Out-of-pocket |
limit Maximum amount a patient needs to pay for covered services. The health insurance pays 100% of covered services when a patient has reached the annual out-of-pocket limit. |
| Outpatient care |
Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor's office, clinic, the patient's home or hospital outpatient department. |
| Over-the-counter drug |
Medicine available in drugstores without providing a prescription |
| POS |
Point-of-Service Plan. A health plan allowing the member to choose to receive a service from a participating or non-participating provider, with different benefits levels. |
| PPO |
Preferred Provider Organization Plan. A network-based, managed care plan that allows the participant to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverage and lower deductibles. |
| Prescription Drug |
A drug that has been approved by the Federal Food and Drug Administration (FDA) which can only be dispensed according to a physician's prescription order. |
| Primary care physician (PCP) |
A physician, usually a family or general practitioner, internist or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's physicians. |
| Referral |
If a primary care physician determines that a participant has a condition which requires the attention of a specialist, the physician makes a referral to a specialist. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. |
| Specialists |
Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral surgery). |
| Status change |
A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, birth of a child, divorce or marriage.
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