Medical Plan Overview

OSU Health Plan Overview

Faculty and staff now have access to two networks: Ohio State University Health Plan Inc. network for services they receive INSIDE Franklin County and access to the Medical Mutual of Ohio SuperMed Plus network for services obtained OUTSIDE Franklin County.

All members in the Prime Care Advantage, Prime Advantage Value and Prime Advantage Plus plans will have access to the same network of providers throughout the state. To see if your providers are in the expanded network or to search for providers in your area, visit our Provider Search.

Medical plans currently offered:

• Prime Care Advantage: Similar to the 2007 University Prime Care, this plan offers a copayment provision and no annual deductible for most services. Services obtained outside the network are not covered under this plan, except in emergency situations.
• Prime Advantage Value: This plan option has the lowest premiums but requires an annual deductible and coinsurance for most services and maintaining copays for certain services, such as ER and physician office visits. Services obtained outside the network are not covered under this plan, except in emergency situations.
• Prime Advantage Plus: This expanded version of the “core plan” offers the same in-network coverage but also provides for out-of-network coverage at a higher premium.
• Independent Choice Plan: All services under this plan can be obtained out of network. Because no network discounts are available, this plan has the highest premiums and requires an annual deductible and coinsurance for all services.
• Out-of-Area Plan: This plan is offered to faculty and staff who live, or whose dependents live, in select areas without adequate network access. You must meet certain criteria to enroll in this plan.

Regardless of your choice, the quality and services are the same across the board, and all options provide 100 percent coverage for preventive care according to Ohio State University Health Plan Inc. guidelines.

Outpatient Procedures Requiring Copay
Check this list for outpatient procedures that require a $100 copay, up to a $300 maximum copay per benefit year, by members of Prime Care Advantage and Prime Advantage Plus in-network health plans. Members of Prime Advantage Plus out-of-network, Prime Advantage Value and Independent Choice plans pay a coinsurance for these procedures as indicated by each plan's schedule of benefits. This list is effective 1/1/2009 and is subject to change.

For more information about monthly premiums, copayments, annual deductibles, coinsurance and benefits coverage, view the Benefit Summary-Medical Plans, Medical Plan Comparison Chart 2009 and the Premium Rates found at http://hr.osu.edu/benefits/healthmedical.htm.

Your Rights and Responsibilities

Covered Person’s Rights
The university is committed to assuring quality health care to its employees. A covered person of any university medical plan has certain rights that will help ensure the receipt of quality health care. A university medical plan member has the right to:

• Receive and have access to information about the functions of the Ohio State University Health Plan Inc., participating health care providers, rules and regulations of the medical plan, and members’ rights and responsibilities;
• Fair and respectful consideration and treatment by the OSU Health Plan staff, the Office of Human Resources staff, NGS American and Express Scripts staff, and health care providers and customer service staff;
• The utmost confidentiality and privacy regarding their health care matters;
• Receive an explanation of all benefits to which they are entitled under your medical plan from the appropriate knowledgeable resources;
• Receive quality health care through the medical plan network in a timely manner, and in the most appropriate setting possible;
• Participate with health care providers in decision-making about health care needs and how best to meet those needs;
• Have access to complete and understandable information about their health conditions, and the treatments rendered by health care providers;
• Refuse treatment and be informed by the health care provider and OSU Health Plan of the consequences of such action;
• Be informed of health wellness, maintenance, and preventive programs to help promote and maintain a healthy lifestyle;
• Express concerns and complaints about health care and administrative services rendered by authorized staff and providers;
• Expect that OSU Health Plan will document concerns and complaints, investigate the situations, and take appropriate action

Covered Person’s Responsibilities
A covered person of a university medical plan has certain responsibilities that will help ensure the receipt of quality health care. A university medical plan member’s responsibilities include:

• Provide, to the best of their ability, complete, honest, and factual information about their health care status as needed by staff and providers to address any health care needs;
• Follow a consensual treatment plan as discussed with, and recommended by the health care providers;
• Listen to and understand the potential consequences that may ensue should they refuse such treatment;
• Understand their health care benefits;
• Inform the Office of Human Resources Customer Service Center of any changes they may have in family status (for example, marriage, divorce, birth or adoption of a child, dependents reaching the limiting age) within the 31 day limit;
• Provide, when requested, complete and factual information to the Office of Human Resources Customer Service Center and NGS American about any other health care coverage or insurance benefits that they may have;
• Treat other members, providers, and administrative staff with respect and consideration; and
• Understand and meet financial obligations for co-payments, deductibles, coinsurance, and non-covered health-related services.

In general:

• Present their identification card before receiving health care services.
• Inform the Office of Human Resources Customer Service Center of any changes they may have in family status (i.e. marriage, divorce, birth or adoption of a child, dependent reaching the limiting age).

When receiving covered medical services:

• At the time of service, pay any annual deductibles, coinsurance, or co-payment amounts which might apply.
• File any claims directly with NGS American, the claims administrator.
• Notify The Ohio State University Health Plan Inc. if admitted to a hospital.

When receiving prescription drugs:

• At the time of a physician visit, the member should discuss the advantages of generic drugs with the provider.
• Seek services from network providers.
• ID Card covered under "In General" above.