Terminology and Plan Rules
56851-0319 GreenState PPO
56851-0419 GreenState HDHP
56851-0309 Insurance PPO
56851-0409 Insurance HDHP
56851-0329 Trust PPO
56851-0429 Trust HDHP
Claim Submission Address:
Wellmark BC/BS of IA
636 Grand Avenue
Des Moines, IA 50309-2565
Deductible is a fixed amount you pay for certain covered services in a benefit year before medical benefits become available. The family deductible is reached from amounts accumulated on behalf of any combination of covered family members.
Coinsurance represents a percentage of cost you pay each time you receive a certain covered service. Coinsurance can be either charged alone, or following deductible.
Copay is a flat fixed fee you pay at the time of service each time you receive certain covered services (office visit, emergency room, prescription drugs).
Out of Pocket Maximum (OPM) is the maximum amount you will pay out of your pocket in any give year. Deductible, coinsurance and copays all apply towards your OPM. A few important notes regarding a Family OPM
If one person on a the family plan with a $6000 OPM meets the individual OPM of $3000 , their personal OPM is considered met for the year.
Additionally, families can meet the out-of-pocket maximum without each family member meeting their individual out-of-pocket maximum. Once the family maximum is met, the plan will then pay 100% of reasonable and customary charges for the rest of the calendar year for all family members. See the example below.
Reasonable and Customary Charges (R&C) are the fees charged by out-of-network providers for comparable services in the same geographic location, as determined by the plan administrator. The reasonable and customary amount is not necessarily the same as the amount your doctor charges.
For example, R&C for a covered service may be $100, but your out-of-network doctor might charge $125 for that service. Assuming you have met the deductible, the plan will pay benefits based on $100. You are then responsible for the balance. Any additional amounts you pay above R&C are not counted towards the annual deductible or out-of-pocket maximum.
Coordination of Benefits (COB) Wellmark follows certain rules to determine which health plan or coverage will pay first when other coverage provides the same or similar benefits. To review Wellmark's rules of coordination, please contact your HR Benefits team via email at firstname.lastname@example.org. Wellmark's Rules of Coordination is also outlined in the Summary Plan Document.
Section 125 Plan Rules and Life Events
Benefit elections made during the initial enrollment period or annual open enrollment are elections that will hold for the entire plan year.
IRS regulations under the Section 125 Plan stipulate that benefit changes are limited to the annual open enrollment period or to an experienced life event.
Experiences life events include such things as marriage, divorce, loss of other coverage, birth of a child, etc.
Notification of an experienced life event must be completed within 30 days of the event.