Iowa Select Plan
The Iowa Select Plan is a comprehensive health care program that covers hospital, medical, surgical, outpatient, and other services such as physical therapy. Coverage is also provided for routine physicals, newborn care (including inoculations, scheduled visits, etc.), well-child check-ups, treatment of mental health conditions, treatment of chemical dependency, and prescription drugs.
How an Individual Uses the Iowa Select Plan
Health care under Iowa Select may be obtained from almost any provider you wish. However, there are advantages to using providers in the Wellmark Alliance Select network.
Select providers will accept payment arrangements with Wellmark Blue Cross and Blue Shield of Iowa. When using select providers you also pay a lower coinsurance percentage and the deductible is waived for services in the office setting.
Care by non-participating providers needed due to medical necessity (examples: referrals or ambulance transportation) may involve higher cost to you. Non-participating providers do not have contracts with Blue Cross and Blue Shield. They do not agree to accept payment arrangements and are not responsible for filing claims for you. Non-participating providers may charge more for health care than participating providers. Payment is made to you and you are responsible for paying the provider. Non-participating providers can bill you for the difference between what Blue Cross and Blue Shield will pay for a service and what they charge (balance billing).
In an emergency, if you cannot reasonably reach a participating provider, emergency care received during the course of the emergency will be reimbursed as though the service were received from a participating provider (excludes ambulance transportation).
Who Can Be Covered
Coverage is provided through Wellmark Blue Cross & Blue Shield of Iowa. There are two contract options available: Employee Only, and Family.
Coverage for children through the end of the calendar year in which they turn 26.
Domestic partners may also be covered on this policy. See the Domestic Partner Information on the Benefits Office web site for more information.
Dual University of Iowa employed spouses/partners and any children may not double insure each other or dependents under the plans where the University contributes towards the cost of the plans. This includes the health, dental, and AD&D insurance policies - an individual may only be included once under these policies.
Pre-existing Condition Clause
This plan has a pre-existing condition waiting period (this does not apply to dependents under the age of 19). This means that as a new enrollee, if you have been diagnosed with, or treated for a specific medical condition within six month’s of the commencement of coverage, there is no coverage for services or supplies related to THAT SPECIFIC CONDITION for a period of 11 months. Some or all of this waiting period may be offset by your prior insurance coverage if you have a 62 day (or less) break in coverage. Your prior insurance company will provide you with a certificate of creditable coverage, and you use this to have all or part of the waiting period waived.
For example, if you were covered by another group health plan (without a break in coverage of 63 days or more) for the 4 month period before your enrollment date, the 11 month waiting period would be reduced to 7 months. If you were covered by another group health plan (without a break in coverage of 63 days or more), for 11 months or more immediately prior to your enrollment date, the entire waiting period would be waived.
How Much an Individual Pays for Health Care Services
Deductibles. The deductible is $250 for single and $500 family coverage. The family deductible is reached from deductible amounts accumulated on behalf of any combination of members. The deductible is waived for services in the office setting from Select providers.
Co-payments. This is a fixed dollar amount you pay each time you receive many covered services. Insureds pay a $15 co-payment for the exam portion of each office visit. There is no co-payment for mental/nervous/substance abuse outpatient visits. Co-payments for office visits on this plan do not apply toward your out-of-pocket maximum (OPM) and they continue after the OPM is met. There is a $50 co-pay for emergency room visits. Emergency room co-payments on this plan do apply toward your out-of-pocket maximum (OPM) and continue after the OPM is met. The emergency room co-payment is waived if you are admitted.
Coinsurance. This is the amount, using a fixed percentage, you pay each time you receive most covered services. The coinsurance percentage for select providers is 10% and it is 20% for non-select providers. There is no coinsurance for emergency room care.
Out-of-Pocket Maximum (OPM) Expenses for Individuals and Families
The Iowa Select Plan provides an annual maximum limit for the out-of-pocket expenses for both individuals and families.
The OPM for the individual's expenses is $600. The OPM for all other contracts is $800. This does not include prescription medication – there is a separate OPM for prescription medication.
When the amount paid equals the applicable OPM, the plan pays 100% of the charges for most additional medically necessary expenses incurred during the remainder of the calendar year.
Amounts an insured pays as deductibles and the percentage portion of charges are cumulated when determining the annual OPM expense. However, co-payments are not counted in determining when the OPM has been exceeded.
Coverage for Prescription Drugs
This plan has a tiered prescription benefit. This means for each prescription you will pay a co-payment, which will vary depending on the tier (or category) of the drug.
The co-payment amounts are:
Tier 1: $5 Wellmark generic formulary
Tier 2: $15 Wellmark name brand formulary
Tier 3: $30 Wellmark non-formulary
You can search the Wellmark Drug List to determine which tier specific medications are in: http://www.wellmark.com/
The pharmacy is responsible for submitting your prescription claims electronically.
Iowa Select has an annual maximum limit for the OPM expense for both individuals and families. The annual OPM is $250 for a Single contract and $500 for the Family contract. This provision can save you money if you have maintenance medications.
This plan also has a mail-order prescription provision that allows you to receive 3 months of a prescription medication while only paying 2 months of co-payments.
If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-payment or coinsurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic. This can result in you paying substantially higher costs than if you had chosen the generic drug.
Mental/Nervous/Substance Abuse Coverage
Inpatient- there is 10% coinsurance after the deductible for select providers; 20% coinsurance after the deductible for non-select providers.
Outpatient- 10% coinsurance for select providers; 20% coinsurance for non-select providers.
Use of mental health network required.
Providers at The University of Iowa Hospitals and Clinics
When care is provided at The University of Iowa Hospitals and Clinics, the individual and the provider will agree on the role residents will play in the individual's care. An individual may choose to have all primary health care provided by faculty members. When an individual is hospitalized, residents and medical students are an integral part of the staff which provides support for treatment by the faculty.
Health Care for Individuals Who Are Away from Iowa
Out-of State . If you are in a state other than Iowa and require medical care, you may call Wellmark Blue Cross and Blue Shield of Iowa for assistance in locating the closest participating provider in that state. For covered services received in a state other than Iowa there are advantages in using providers who participate with the Blue Cross and Blue Shield Plan in that state.
Out-of-Country. If it is necessary to receive covered services in a country other than the United States, it is advisable to contact Blue Cross and Blue Shield for assistance in locating the closest participating provider in that country.