State Program III Plus
State Program III Plus is a comprehensive health care program that covers hospital, medical, surgical, outpatient, and other health care services such as physical therapy. Coverage is also provided for routine physicals, newborn care (including inoculations, scheduled visits, etc.), well-child checkups, treatment of mental health conditions, treatment of chemical dependency, and prescription drugs.
How an Individual Uses Program III Plus
Health care under the Program III Plus may be obtained from almost any provider you wish. However, there are advantages to using participating providers who have contracts with Blue Cross and Blue Shield.
In Iowa, participating providers will accept payment arrangements and file claims for you with Wellmark Blue Cross and Blue Shield of Iowa. Payment is made directly to these providers.
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 ambulances).
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 website 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 only place this plan has a deductible is Inpatient hospital services. The deductible is $300 for single and $400 family coverage. The family deductible is reached from deductible amounts accumulated on behalf of any combination of members.
Co-payments. This is a fixed dollar amount you pay each time you receive many covered services. The Co-payment for the exam portion of each office visit on this plan is $15. There is no co-pay for mental/nervous/substance abuse outpatient visits.Co-payments on this plan do not apply toward your out-of-pocket maximum (OPM) and they continue after the OPM is met.
Coinsurance. This is the amount, using a fixed percentage, you pay each time you receive most covered services. The coinsurance percentage for Program III Plus is 20%. There is no coinsurance for emergency room care.
Out-of-Pocket Maximum (OPM) Expenses for Individuals
Program III Plus has an annual maximum limit for the OPM expense for both individuals and families. The annual OPM is $600 for a Single contract and $800 for the Family contract. 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. You have coverage for most prescription drugs and medicines.
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.
Program III Plus 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.
Participating (Blue Cross/Blue Shield)--These providers participate with a Blue Cross and Blue Shield Plan.
Nonparticipating--These providers do not participate with a Blue Cross and Blue Shield Plan.
Participating (Blue Cross/Blue Shield)--Blue Cross and Blue Shield has contracts with these providers and they agree to accept payment arrangements.
Nonparticipating--Blue Cross and Blue Shield does not have contracts with these providers and they do not agree to accept payment arrangements.
Participating (Blue Cross/Blue Shield)--These providers file claims for you.
Nonparticipating--These providers are not responsible for filing claims for you. You may have to file you own claims.
Participating (Blue Cross/Blue Shield)--Claims are settled directly with these providers.
Nonparticipating--Claims are settled with you, not these providers.
Participating Providers. All hospitals in Iowa are participating providers and over 4,000 physicians in Iowa are also participating providers.
Emergency Services. If you receive emergency care for covered services and cannot reasonably reach a participating provider, emergency care received during the course of the emergency will be reimbursed as though the services were received from a participating provider.
Mental/Nervous/Substance Abuse Coverage
Inpatient – there is 20% coinsurance after the deductible.
Outpatient – no charge
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.