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2015 Plan Overview
IND
IVID
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Exclusive wellness resources
Our FitTogether™ wellness programs and services include:
• Access to ProvRN for free health advice, 24/7, from a registered nurse
• Tobacco cessation programs to help tobacco users quit for good
• Award-winning care managers who provide education and support for chronic conditions, such as asthma and diabetes
• Health and wellness classes to help you manage stress, achieve a healthy weight, begin a yoga practice and more
• An award-winning newsletter packed with health and wellness information from Providence health experts
Innovative tools to maintain and improve health
• With myProvidence, our secure member portal and complete source for health, wellness and benefits information, you can:
• Get a baseline of your overall health with a personal health assessment
• Search our online directory to find in-network providers, review your claims history and calculate how much of your deductible you’ve met
• Manage your health costs with our treatment cost estimator and online bill pay options
• Improve your health with Wellness Central, an integrated health and wellness hub that offers a personalized dashboard, health trackers and assessments, a library of health videos and articles, meal plans and medication information
• With MyChart, a secure website for Providence Medical Group patients, you can:
° Schedule appointments online
° Email your PMG provider
° Pay bills online
° Access your lab and test results
Health-enhancing extras for better fitness and more fun
As a Providence Health Plan member, you can enjoy savings on:
• Exclusive recreation discounts through LifeBalance for:
° Popular local and national family attractions, such as zoos and amusement parks
° Hundreds of fitness facilities throughout Oregon
° Discounted tickets to local events, savings at hotels nationwide and more
• Board-certified LASIK vision correction or custom LASIK through our partner, TruVision
• Hearing aids (up to 60 percent off) through our partner, TruHearing
This booklet offers an overview of our individual and family plans and premiums, which
are subject to change every year. For more information about plan benefits and enrollment
requirements, limitations and exclusions, see the plan contract or contact our sales team or your
insurance producer. To view a benefit summary, go to www.ProvidenceHealthPlan.com/sbc2015.
Your partner in health and wellnessChoosing a health plan is a big decision. Sure, you want someone who’ll cover your
treatments when you’re sick. But it’s really about having a partner who encourages
you to feel better and live well every day. Your pursuit of health and happiness is
a unique journey. You deserve a partner who will go the distance with you.
Why choose Providence?You’ll find a plan and options to fit your unique needs
• We offer a broad range of plan types and cost-sharing options (e.g., deductible, coinsurance and copayment).
• Our networks range from a local base of medical home providers to nearly 1 million providers nationwide.
Everyone deserves better health.
• It’s our Mission to take care of people in need, which is why we strive to improve the quality of life for those in the communities we serve by donating vital health care services.
• For the past eight years, we have been recognized by the Portland Business Journal as one of the most admired health care companies.
• We’re a local, not-for-profit health plan that understands the specific issues and challenges of Oregonians.
Experience and innovation mean better care for you.
• We’re part of Providence Health & Services, one of the nation’s top 10 most-integrated health care providers, serving the Pacific Northwest for nearly 160 years.
• We’re innovative. With telemedicine and close coordination between our hospitals and clinics, you get better care.
We’re easy to work with.
• Our friendly, local customer service representatives process claims promptly. They answer your calls quickly and go the extra mile to resolve issues as fast as possible.
• You can get online claims and benefits information easily through myProvidence, a one-stop resource that can help you better understand and use your health plan benefits.
You get more for your health – and your health care dollar.
• You’ll receive discounts on massage therapy, fitness classes, gym memberships, LASIK and other extras to keep you healthy, happy and engaged in life.
• With our online tools and classes, you can stay on target with your health and wellness goals.
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Your lifestyle, your planChoose a 2015 health plan that best fits your life, and your health. You’ll find robust benefits
and extensive provider choices; an HSA-qualified plan that lets you save tax-free dollars for
future medical expenses; and two plan types centered on a medical home model that lets
you choose a primary care clinic near you with a health care team to coordinate your care.
Alternative care options
If you prefer to see a naturopath or other alternative care provider for covered benefits, including periodic exams and well-baby care, those services are covered at the same rate as they would be for a primary care physician, as long as the provider is licensed to perform the service provided.
The Balance, Choice and Connect plans cover chiropractic manipulation and acupuncture with a $25 copay when you visit an in-network provider.
Flexibility to change plans
We get it. Life throws curve balls that can change your financial situation. When you buy from Providence, you can switch to a plan with a lower premium once during the contract year. If you buy your plan through the Federal Health Insurance Marketplace, any changes in plans throughout the year are subject to approval by the Marketplace.
Pediatric dental coverage
Pediatric dental care is an essential health benefit required by the ACA. It is included in all our medical plans, except the Essential and Standard plans. For your convenience and savings, dental benefits are subject to the medical deductible and out-of-pocket maximum.
There’s a Providence plan for you and your family, no matter where you live in Oregon.
Balance, HSA Qualified, Standard, Choice and Essential plans are available throughout Oregon. Your rate will be calculated according to your age, whether you use tobacco, and the county you live in. See the map on page 21 to find your rate area.
Bent
on
Clackamas
Clatsop
Columbia
Crook
Deschutes
Douglas
Gilliam
Harney
Hood River
Jackson
Jefferson
Josephine Klamath
Lane
Linn
Marion
Multnomah
PolkWasco
Washington
Wheeler
Yamhill
Lin
coln
Coos
Curry
Lake
Malheur
Sher
man
Tillam
ook
MorrowUnion
Baker
Grant
Umatilla Wallowa
Connect plans are available only in Multnomah, Clackamas and Washington counties.
Clackamas
Columbia
Hood River
Marion
Multnomah
Polk
Washington
Yamhill
Where to buy plansPurchase the right Providence plan for you at www.ProvidenceHealthPlan.com, or ask
a Providence representative or your insurance producer for help. Providence plans are also
available through the Federal Health Insurance Marketplace at HealthCare.gov.
Metal tierPlans available directly
from Providence or your producer
Plans available from the Federal Health
Insurance Marketplace at HealthCare.gov
Balance 2000 Silver Silver •
Balance 4000 Silver Silver •
HSA Qualified 2800 Bronze Bronze •
Choice 2000 Silver Silver • •
Choice 4000 Silver Silver •
Connect 2000 Silver Silver • •
Connect 4000 Silver Silver •
Providence Oregon Standard Gold Plan Gold • •
Providence Oregon Standard Silver Plan Silver • •
Providence Oregon Standard Bronze Plan Bronze • •
Providence Essential Catastrophic • •
Compare plans • Check rates • Apply and enroll online
We can help you find the right plan. Apply and enroll:
• Online at www.ProvidenceHealthPlan.com
• Over the phone with a Providence representative
Portland metro area 503-574-5000
All other areas 800-988-0088
Monday through Friday, 8 a.m. to 8 p.m.
• With your insurance producer
Apply during open enrollment from Nov. 15, 2014, through Feb. 15, 2015. After the open enrollment period ends, you must have a qualifying life event to enroll in a health insurance plan. Qualifying life events include losing employer coverage, marriage and the birth of a child. See a list of qualifying life events at www.ProvidenceHealthPlan.com.
6 7
BalanceBalance plans are just that, a balance of cost-saving features and coverage
for the services you use the most.
The plans include:
• No deductible for primary care, generic drugs, and lab and X-ray services; your only out-of-pocket expense is your copay, where applicable
• A deductible you can apply to the out-of-pocket maximum
• Coverage for routine vision services, including glasses and contacts
• The freedom to choose any provider, in and out of the Providence EPO Network
• Pediatric dental coverage
Providence EPO Network: A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations.
Balance
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Balance 2000 Silver Balance 4000 Silver
in-network out-of-network in-network out-of-network
Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000
Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600
Accidental Injury Benefit The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury.
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full ✓ 50% Covered in full ✓ 50%
Maternity prenatal care Covered in full ✓ 50% Covered in full ✓ 50%
Gynecological exams; Pap tests Covered in full ✓ 50% Covered in full ✓ 50%
Mammograms Covered in full ✓ 50% Covered in full ✓ 50%
Colorectal cancer screenings (age 50 and over) Covered in full ✓ 50% Covered in full ✓ 50%
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Balance 2000 Silver Balance 4000 Silver
in-network out-of-network in-network out-of-network
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider $25 ✓ 50% $25 ✓ 50%
Specialist $50 ✓ 50% $50 ✓ 50%
Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) $25 ✓ 50% $25 ✓ 50%
HOSPITAL SERVICES
Inpatient hospital services and maternity care 30% 50% 30% 50%
EMERGENCY/URGENT CARE
Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30%
Urgent care services $75 ✓ 50% $75 ✓ 50%
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services 30% ✓ 50% 30% ✓ 50%
High tech imaging services (such as PET, CT, MRI) 30% 50% 30% 50%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services 30% 50% 30% 50%
Outpatient provider visits $25 ✓ 50% $25 ✓ 50%
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility 30% 50% 30% 50%
Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) $25 ✓ 50% $25 ✓ 50%
PRESCRIPTION DRUGS
Generic $15 ✓ Not Covered $15 ✓ Not Covered
Preferred brand name $60 ✓ Not Covered $60 ✓ Not Covered
Non-preferred brand name and specialty 50% Not Covered 50% Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year) Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year) $30 ✓ Covered ✓ $30 ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered ✓ Covered ✓ Covered ✓ Covered ✓
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Covered in full ✓ 30% ✓ Covered in full ✓ 30% ✓
Basic services (includes restorative fillings - silver and composite, and space maintainers) 50% 70% 50% 70%
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures)
50% 70% 50% 70%
Balance (continued)
8 9
HSA QualifiedThese lower-premium, high-deductible health plans give you affordable coverage and the
flexibility to choose any provider. With an HSA Qualified plan, paired with a tax-exempt
savings account, you save pre-tax dollars to pay for future health care expenses.
HSA Qualified plans offer:
• Care from specialists without a referral
• Lower premiums with most services subject to the deductible
• In-network preventive care and adult routine vision services that are covered before the deductible
• The freedom to choose any provider, in or out of the Providence EPO Network
• A deductible that applies to the out-of-pocket maximum
• Pediatric dental coverage
• A preferred rate and easy set-up when you open a health savings account with HealthEquity®, a partner of Providence Health Plan
Providence EPO Network: A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations.
HSA Qualified
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
HSA Qualified 2800 Bronze
in-network out-of-network
Annual Deductible Individual/Family $2,800/$5,600 $5,600/$11,200
Annual Out-of-Pocket Maximum Individual/Family $6,200/$12,400 $12,400/$24,800
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full ✓ 50%
Maternity prenatal care Covered in full ✓ 50%
Gynecological exams; Pap tests Covered in full ✓ 50%
Mammograms Covered in full ✓ 50%
Colorectal cancer screenings (age 50 and over) Covered in full ✓ 50%
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
HSA Qualified 2800 Bronze
in-network out-of-network
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider 50% 50%
Specialist 50% 50%
Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) 50% 50%
HOSPITAL SERVICES
Inpatient hospital services and maternity care 50% 50%
EMERGENCY/URGENT CARE
Emergency services 50% 50%
Urgent care services 50% 50%
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services 50% 50%
High tech imaging services (such as PET, CT, MRI) 50% 50%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services 50% 50%
Outpatient provider visits 50% 50%
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility 50% 50%
Chiropractic manipulation and acupuncture Not Covered Not Covered
PRESCRIPTION DRUGS
Generic 50% Not Covered
Preferred brand name 50% Not Covered
Non-preferred brand name and specialty 50% Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year) Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year) $25 ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Not Covered Not Covered
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Covered in full ✓ 30% ✓
Basic services (includes restorative fillings - silver and composite, and space maintainers) 50% 70%
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) 50% 70%
HSA Qualified (continued)
10 11
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Choice 2000 Silver Choice 4000 Silver
in-network out-of-network in-network out-of-
network
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider $25 ✓ 50% $25 ✓ 50%
Specialist $50 ✓ 50% $50 ✓ 50%
Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) $25 ✓ 50% $25 ✓ 50%
HOSPITAL SERVICES
Inpatient hospital services and maternity care 30% 50% 30% 50%
EMERGENCY/URGENT CARE
Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30%
Urgent care services $75 ✓ 50% $75 ✓ 50%
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services 30% ✓ 50% 30% ✓ 50%
High tech imaging services (such as PET, CT, MRI) 30% 50% 30% 50%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services 30% 50% 30% 50%
Outpatient provider visits $25 ✓ 50% $25 ✓ 50%
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility 30% 50% 30% 50%
Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) $25 ✓ 50% $25 ✓ 50%
PRESCRIPTION DRUGS
Generic $15 ✓ Not Covered $15 ✓ Not Covered
Preferred brand name $60 ✓ Not Covered $60 ✓ Not Covered
Non-preferred brand name and specialty 50% Not Covered 50% Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year) Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year) $30 ✓ Covered ✓ $30 ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered ✓ Covered ✓ Covered ✓ Covered ✓
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Covered in full ✓ 30% ✓ Covered in full ✓ 30% ✓
Basic services (includes restorative fillings - silver and composite, and space maintainers) 50% 70% 50% 70%
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures)
50% 70% 50% 70%
ChoiceChoice plans utilize a medical home model which provides a team of health
professionals dedicated to each member’s overall well-being. Members select a
medical home at time of enrollment from the Providence Choice Network. The medical
home team then works collaboratively to support all aspects of a member’s health,
from wellness and prevention to active management of chronic conditions.
Choice plans offer:
• More than 200 medical home clinics in Oregon and southwest Washington that provide a patient-focused, coordinated care experience
• Access a broad network of specialists and facilities via referral from the medical home in order to receive coverage at the in-network level
• Deductibles waived for doctor and specialist visits, urgent care, lab and X-ray services, chiropractic manipulation and acupuncture, and generic and preferred brand-name drugs
• Higher cost shares for select services such as knee and hip replacement, sleep studies, and sinus surgery
• Separate deductibles and out-of-pocket maximums in and out of the network
• Pediatric dental coverage
• Adult vision coverage (exams and hardware)
Providence Choice Network: A network of over 200 primary care clinics located throughout Oregon and southwest Washington designated as medical homes
Bent
on
Clackamas
Clatsop
Columbia
Crook
Deschutes
Douglas
Gilliam
Harney
Hood River
Jackson
Jefferson
Josephine Klamath
Lane
Linn
Marion
Multnomah
PolkWasco
Washington
Wheeler
Yamhill
Lin
coln
Coos
Curry
Lake
Malheur
Sher
man
Tillam
ook
MorrowUnion
Baker
Grant
KlickitatSkam
aniaCowlitz
Clark
Wahkiakum
Umatilla Wallowa
For a complete list of medical homes and providers by location, visit www.ProvidenceHealthPlan.com/providerdirectory.
Choice
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Choice 2000 Silver Choice 4000 Silver
in-network out-of-network in-network out-of-
network
Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000
Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600
Accidental Injury Benefit The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury.
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full ✓ 50% Covered in full ✓ 50%
Maternity prenatal care Covered in full ✓ 50% Covered in full ✓ 50%
Gynecological exams; Pap tests Covered in full ✓ 50% Covered in full ✓ 50%
Mammograms Covered in full ✓ 50% Covered in full ✓ 50%
Colorectal cancer screenings (age 50 and over) Covered in full ✓ 50% Covered in full ✓ 50%
Choice (continued)
12 13
ConnectConnect plans combine a medical home model of care with a narrow provider network
to achieve substantial premium savings. Members choose a medical home at time of
enrollment from our Portland metro-area Providence Connect Network. The medical
home model provides a team of health professionals dedicated to your overall well-
being. The medical home team members work collaboratively to support all aspects of
your health, from wellness and prevention to active management of chronic conditions.
Connect plans offer:
• More than 65 medical home clinics in the Portland metro area
• Access to specialists and facilities via referral from the medical home in order to receive coverage at the in-network level
• A deductible that applies to the out-of-pocket maximum
• No deductible for doctor and specialist visits, lab and X-ray services, and generic drugs
• Pediatric dental coverage
• Higher cost shares for select services such as knee and hip replacement, sleep studies, and sinus surgery
Providence Connect Network: A Portland-area network of over 65 primary care clinics in Multnomah, Washington and Clackamas counties designated as medical homes.
Clackamas
Columbia
Hood River
Marion
Multnomah
Polk
Washington
Yamhill
For a complete list of medical homes and providers by location, visit www.ProvidenceHealthPlan.com/providerdirectory.
Connect
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Connect 2000 Silver Connect 4000 Silver
in-network out-of-network in-network out-of-
network
Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000
Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600
Accidental Injury Benefit The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury.
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full ✓ 50% Covered in full ✓ 50%
Maternity prenatal care Covered in full ✓ 50% Covered in full ✓ 50%
Gynecological exams; Pap tests Covered in full ✓ 50% Covered in full ✓ 50%
Mammograms Covered in full ✓ 50% Covered in full ✓ 50%
Colorectal cancer screenings (age 50 and over) Covered in full ✓ 50% Covered in full ✓ 50%
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Connect 2000 Silver Connect 4000 Silver
in-network out-of-network in-network out-of-
network
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider $25 ✓ 50% $25 ✓ 50%
Specialist $50 ✓ 50% $50 ✓ 50%
Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) $25 ✓ 50% $25 ✓ 50%
HOSPITAL SERVICES
Inpatient hospital services and maternity care 30% 50% 30% 50%
EMERGENCY/URGENT CARE
Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30%
Urgent care services $75 ✓ 50% $75 ✓ 50%
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services 30% ✓ 50% 30% ✓ 50%
High tech imaging services (such as PET, CT, MRI) 30% 50% 30% 50%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services 30% 50% 30% 50%
Outpatient provider visits $25 ✓ 50% $25 ✓ 50%
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility 30% 50% 30% 50%
Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) $25 ✓ 50% $25 ✓ 50%
PRESCRIPTION DRUGS
Generic $15 ✓ Not Covered $15 ✓ Not Covered
Preferred brand name $60 ✓ Not Covered $60 ✓ Not Covered
Non-preferred brand name and specialty 50% Not Covered 50% Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year) Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered in full ✓ Covered ✓ Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year) $25 ✓ Covered ✓ $25 ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Not Covered Not Covered Not Covered Not Covered
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Covered in full ✓ 30% ✓ Covered in full ✓ 30% ✓
Basic services (includes restorative fillings - silver and composite, and space maintainers) 50% 70% 50% 70%
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures)
50% 70% 50% 70%
Connect (continued)
14 15
StandardBenefits for Standard plans are defined by the state of Oregon. Choose a Gold, Silver or Bronze plan with deductibles ranging from $1,300 to $5,000.
Standard plans offer:
• Copays starting as low as $20 and deductibles as low as $1,300
• A deductible that applies to the out-of-pocket maximum
• The freedom to choose any provider in and out of the Providence EPO Network
• The Providence Oregon Standard Bronze Plan is HSA qualified
To note: Standard plans do not cover chiropractic manipulation, acupuncture, adult routine vision exams and vision hardware, or pediatric dental services.
Providence EPO Network: A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations.
Standard
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Providence Oregon Standard Gold
Providence Oregon Standard Silver
Providence Oregon Standard Bronze
in-network
out-of-network
in-network
out-of-network
in-network
out-of-network
Annual Deductible Individual/Family $1,300/ $2,600
$2,600/ $5,200
$2,500/ $5,000
$5,000/ $10,000
$5,000/ $10,000
$10,000/ $20,000
Annual Out-of-Pocket Maximum Individual/Family
$6,350/ $12,700
$12,700/ $25,400
$6,350/ $12,700
$12,700/ $25,400
$6,350/ $12,700
$12,700/ $25,400
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service)
Covered in full ✓ 50% Covered in
full ✓ 50% Covered in full ✓ 50%
Maternity prenatal care Covered in full ✓ 50% Covered in
full ✓ 50% Covered in full ✓ 50%
Gynecological exams; Pap tests Covered in full ✓ 50% Covered in
full ✓ 50% Covered in full ✓ 50%
Mammograms Covered in full ✓ 50% Covered in
full ✓ 50% Covered in full ✓ 50%
Colorectal cancer screenings (age 50 and over)
Covered in full ✓ 50% Covered in
full ✓ 50% Covered in full ✓ 50%
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider $20 ✓ 50% $35 ✓ 50% $60 50%
Specialist $40 ✓ 50% $70 ✓ 50% $100 50%
Alternative care provider (e.g.,naturopath, chiropractor, acupuncturist)
$40 ✓ 50% $70 ✓ 50% $100 50%
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Providence Oregon Standard Gold
Providence Oregon Standard Silver
Providence Oregon Standard Bronze
in-network
out-of-network
in-network
out-of-network
in-network
out-of-network
HOSPITAL SERVICES
Inpatient hospital services and maternity care 10% 50% 30% 50% 50% 50%
EMERGENCY/URGENT CARE
Emergency services 10% 10% 30% 30% 50% 50%
Urgent care services $60 ✓ 50% $90 ✓ 50% $120 50%
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services 10% 50% 30% 50% 50% 50%
High tech imaging services (such as PET, CT, MRI) 10% 50% 30% 50% 50% 50%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services 10% 50% 30% 50% 50% 50%
Outpatient provider visits $20 ✓ 50% $35 ✓ 50% $60 50%
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility 10% 50% 30% 50% 50% 50%
Chiropractic manipulation and acupuncture
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
PRESCRIPTION DRUGS
Generic $10 ✓ Not Covered $15 ✓ Not
Covered $20 Not Covered
Preferred brand name $30 ✓ Not Covered $50 ✓ Not
Covered $80 Not Covered
Non-preferred brand name and specialty 50% ✓ Not Covered 50% ✓ Not
Covered 50% Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year)
Covered in full ✓ Covered ✓ Covered
in full ✓ Covered ✓ Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply
Covered in full ✓ Covered ✓ Covered
in full ✓ Covered ✓ Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year)
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Vision hardware (frames, lenses, contact lenses) Limits apply
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants)
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Basic services (includes restorative fillings - silver and composite, and space maintainers)
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures)
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Standard (continued)
16 17
EssentialThe Essential plan covers you in case of unforeseen major medical expenses.
This catastrophic plan is available only to individuals aged 29 years and younger.
The Essential plan offers:
• Affordable coverage with lower monthly premiums
• Coverage for up to three personal physician/provider office visits per calendar year before the deductible is met
• Prescription drug coverage
• The freedom to choose any provider, in and out of the Providence EPO Network
Providence EPO Network: A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations.
Essential
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Providence Essential
in-network out-of-network
Annual Deductible Individual/Family $6,600/$13,200 $13,200/$26,400
Annual Out-of-Pocket Maximum Individual/Family $6,600/$13,200 $13,200/$26,400
PREVENTIVE CARE
Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full ✓ Covered in full
Maternity prenatal care Covered in full ✓ Covered in full
Gynecological exams; Pap tests Covered in full ✓ Covered in full
Mammograms Covered in full ✓ Covered in full
Colorectal cancer screenings (age 50 and over) Covered in full ✓ Covered in full
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider 50% first 3 visits ✓ Covered in full
Specialist Covered in full Covered in full
Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) Covered in full Covered in full
After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with ✓
Providence Essential
in-network out-of-network
HOSPITAL SERVICES
Inpatient hospital services and maternity care Covered in full Covered in full
EMERGENCY/URGENT CARE
Emergency services Covered in full Covered in full
Urgent care services Covered in full Covered in full
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services Covered in full Covered in full
High tech imaging services (such as PET, CT, MRI) Covered in full Covered in full
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services Covered in full Covered in full
Outpatient provider visits Covered in full Covered in full
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospital-based facility Covered in full Covered in full
Chiropractic manipulation and acupuncture Not Covered Not Covered
PRESCRIPTION DRUGS
Generic Covered in full Not Covered
Preferred brand name Covered in full Not Covered
Non-preferred brand name and specialty Covered in full Not Covered
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year) Covered in full ✓ Covered ✓
Vision hardware (frames, lenses, contact lenses) Limits apply Covered in full ✓ Covered ✓
ADULT VISION SERVICES
Routine eye exams (limited to one exam per calendar year) Not Covered Not Covered
Vision hardware (frames, lenses, contact lenses) Limits apply Not Covered Not Covered
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Not Covered Not Covered
Basic services (includes restorative fillings - silver and composite, and space maintainers) Not Covered Not Covered
Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) Not Covered Not Covered
Essential (continued)
18 19
Compare our 2015 plans side-by-side
Plan nameProvidence
Oregon Standard Gold Plan
Providence Oregon Standard
Silver Plan
Balance 2000 Silver
Balance 4000 Silver
Choice 2000 Silver
Choice 4000 Silver
Connect 2000 Silver
Connect 4000 Silver
HSA Qualified 2800 Bronze
Providence Oregon
Standard Bronze Plan
Providence Essential
Metal level Gold Silver Silver Silver Silver Silver Silver Silver Bronze Bronze Catastrophic
Where to buyProvidence Health Plan/Agent and/or
Marketplace
Providence Health Plan/Agent and/or
Marketplace
Providence Health Plan/Agent
Providence Health Plan/Agent
Providence Health Plan/
Agent and/or Marketplace
Providence Health Plan/
Agent
Providence Health Plan/
Agent and/or Marketplace
Providence Health Plan/
Agent
Providence Health Plan/
Agent
Providence Health Plan/
Agent and/or Marketplace
Providence Health Plan/Agent and/or
Marketplace
Annual Deductible Individual/Family $1,300/$2,600 $2,500/$5,000 $2,000/$4,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000 $2,800/$5,600 $5,000/$10,000 $6,600/$13,200
Annual Out-of-Pocket Maximum Individual/Family $6,350/$12,700 $6,350/$12,700 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $6,200/$12,400 $6,350/$12,700 $13,200/$26,400
Accidental Injury Benefit Not covered Not covered The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury Not covered Not covered Not covered
PPP office visit $20 ✓ $35 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ 50% $60 50% first 3 visits ✓
Specialist office visit $40 ✓ $70 ✓ $50 ✓ $50 ✓ $50 ✓ $50 ✓ $50 ✓ $50 ✓ 50% $100 Covered in full
Chiropractic manipulation & Acupuncture Not Covered Not Covered $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ Not Covered Not Covered Not Covered
Prescription Drugs (generic) $10 ✓ $15 ✓ $15 ✓ $15 ✓ $15 ✓ $15 ✓ $15 ✓ $15 ✓ 50% $20 Covered in full
Preferred brand name drugs $30 ✓ $50 ✓ $60 ✓ $60 ✓ $60 ✓ $60 ✓ $60 ✓ $60 ✓ 50% $80 Covered in full
Inpatient Hospital 10% 30% 30% 30% 30% 30% 30% 30% 50% 50% Covered in full
Emergency services 10% 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% 50% 50% Covered in full
Urgent care visits $60 ✓ $90 ✓ $75 ✓ $75 ✓ $75 ✓ $75 ✓ $75 ✓ $75 ✓ 50% $120 Covered in full
Mental health - Outpatient visits $20 ✓ $35 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ $25 ✓ 50% $60 Covered in full
Outpatient diagnostic lab & x-ray 10% 30% 30% ✓ 30% ✓ 30% ✓ 30% ✓ 30% ✓ 30% ✓ 50% 50% Covered in full
Adult vision exams Not covered Not covered $30 ✓ $30 ✓ $30 ✓ $30 ✓ $25 ✓ $25 ✓ $25 ✓ Not covered Not covered
Pediatric vision (exams & hardware) Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓ Covered in full ✓
Pediatric Dental Not Covered Not Covered Covered Covered Covered Covered Covered Covered Covered Not covered Not covered
Premium examples for non-tobacco users for rating Region A (Clackamas, Multnomah, Washington and Yamhill* counties)
Single, 26 years old $219 $187 $199 $186 $185 $173 $170 $159 $165 $158 $152
Single, 55 years old $477 $408 $433 $406 $404 $377 $370 $346 $359 $343 N/A
Family: parents aged 38 & 40, children aged 7 & 10 $812 $694 $736 $692 $687 $641 $629 $587 $611 $585 N/A
Networks EPO Network Choice Network Connect Network EPO Network
A network of nearly 1 million health care providers nationwide, both in providence facilities and in
other locations
A network of over 200 primary care clinics located throughout
Oregon and southwest Washington designated as medical homes
A Portland-area network of over 65 primary care clinics in Multnomah, Washington and Clackamas counties
designated as medical homes
A network of nearly 1 million health care providers nationwide, both in providence facilities and in
other locations
Bent
on
Clackamas
Clatsop
Columbia
Crook
Deschutes
Douglas
Gilliam
Harney
Hood River
Jackson
Jefferson
Josephine Klamath
Lane
Linn
Marion
Multnomah
PolkWasco
Washington
Wheeler
Yamhill
Lin
coln
Coos
Curry
Lake
MalheurSh
erm
an
Tillam
ook
MorrowUnion
Baker
Grant
KlickitatSkam
aniaCowlitz
Clark
Wahkiakum
Umatilla Wallowa
Clackamas
Columbia
Hood River
Marion
Multnomah
Polk
Washington
Yamhill
*Connect plans are not available for purchase in Yamhill county.
✓ Deductible waived for these services PLEASE NOTE: Benefit examples shown above for in-network coverage only. For the full listing of in- and out-of-network benefits, visit www.ProvidenceHealthPlan.com
20 21
Individual and Family plan rates for 2015Several factors make up your monthly premium rate:
• Your age
• Whether or not you use tobacco
• The county where you live
Providence has combined Oregon counties into three rate groups:
Group A: Clackamas, Multnomah, Washington, Yamhill
Group B: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk
Group C: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
To determine the premium for yourself as an individual, go to the rate sheet for the county in which you live, use your age and choose the plan that fits your needs.
To determine the premium for you and your family, go to the rate sheet for the county in which you live, choose the plan that fits your needs, then use the ages for each person to be covered. Add the premium amounts for each family member to determine your total. If you’re covering more than three children 20 years of age and younger, add only the premiums for your first three children.
PLEASE NOTE: Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.
Glossary of TermsAccidental injury
An injury that is due directly to an unintentional act, independent of all other causes.
Calendar year
The period from January 1 through December 31 each year.
Coinsurance
A percentage of the amount you are responsible to pay a health care provider for a covered service. For example, if a health care service is covered at a 20 percent coinsurance, you would pay 20 percent of the covered costs and the plan would pay 80 percent.
Copay
A fixed dollar amount that you are responsible for paying to a health care provider at the time you receive the service. For example, if an office visit is covered at a $20 copay, you would pay $20 and the plan would pay the remaining balance.
Deductible
A deductible is the amount you must pay for services that are that are covered by the health plan before your plan will begin to pay for these services. A new deductible must be met each calendar year.
Dependent
A person who is supported by the policyholder or the policyholder’s spouse.
Effective date of coverage
Effective date of coverage means the date upon which coverage starts for a newly-enrolled health plan member.
Exclusion
A service or supply not covered by the health plan.
Exclusion period
A period of time during which all specified treatments or procedures are excluded from coverage. If treatment was covered under a previous plan, then the exclusion period is reduced by each day of continuous prior creditable coverage.
Limitations
Certain covered services have a plan maximum for coverage for a set period of time, usually a calendar year.
Marketplace
Also called an “exchange,” a health insurance marketplace is an online place where you can buy health coverage. If you qualify for a tax credit or subsidy to help pay for your coverage, you must buy your health plan through the Federal Health Insurance Marketplace, located at HealthCare.gov.
Member
A policyholder or eligible spouse or dependent who is properly enrolled in the plan.
Non-participating provider
A health care provider or facility with no agreement to participate with Providence Health Plan. When you use non-participating providers, you receive out-of-network benefits and pay a higher coinsurance for your share of the costs.
Out-of-pocket maximum
The total amount you will pay in the deductible, copays and coinsurance for covered services in a calendar year. After you meet your plan’s out-of-pocket maximum, the plan will pay for 100 percent of covered serviced for the remainder of the year.
Participating provider
A health care provider or facility with an agreement to participate with providence Health Plan. When you use participating providers you receive in-network benefits and have lower costs.
Personal physician/provider
A participating provider who has agreed to provide or coordinate medical care and is listed in the personal physician/provider section of the Provider Directory.
Premium
The monthly rate you pay for health plan coverage.
Provider network
A provider network is a collection of physicians, hospitals, and facilities that have agreed to set reimbursement rates for health care services delivered to members of a health insurance plan. Providence Health Plan has three networks that are matched to our various plans.
Service area
The geographic area in Oregon where the policyholder, spouse of the policyholder or child-only member must physically reside in order to qualify for coverage. Plan availability may vary by county.
22 23
Individual and Family Plan Rates, Group A: Non-Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 263 271 280 291 303 317 331 346 362 379 396 414 433 453 473 494 505 527 545 557 573 582
Balance 4000 Silver Silver 247 254 263 273 284 298 310 325 339 355 371 389 406 425 444 464 474 494 511 523 537 546
HSA Qualified 2800 Bronze Bronze 218 225 232 242 252 263 275 288 300 314 328 344 359 376 392 410 419 437 452 463 475 483
Choice 2000 Silver* Silver 246 253 261 272 283 296 309 323 338 353 369 386 404 422 441 461 471 491 509 520 534 543
Choice 4000 Silver Silver 229 236 244 254 264 276 288 302 315 330 345 361 377 394 412 431 440 459 475 486 499 507
Connect 2000 Silver* Silver 225 232 240 249 259 271 283 296 310 324 339 354 370 387 405 423 432 451 466 477 490 498
Connect 4000 Silver Silver 210 217 224 233 242 253 264 277 289 303 316 331 346 362 378 395 403 421 436 445 458 465
Providence Oregon* Standard Gold Plan Gold 290 299 309 321 334 350 365 382 399 418 437 457 477 499 522 545 557 581 601 615 632 642
Providence Oregon* Standard Silver Plan Silver 248 256 264 275 286 299 312 327 341 357 373 391 408 427 446 466 476 497 514 526 540 549
Providence Oregon* Standard Bronze Plan Bronze 209 215 222 231 241 252 263 275 287 301 314 329 343 359 375 392 401 418 433 442 455 462
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $123 194 194 194 194 195 199 203 211 217 220 225 230 232 236 237 239 240 242 245 248 253 257
Balance 4000 Silver Silver $116 182 182 182 182 183 186 191 198 204 207 211 215 218 221 222 224 225 227 230 233 237 241
HSA Qualified 2800 Bronze Bronze $102 161 161 161 161 162 165 169 175 180 183 187 190 193 195 197 198 199 201 203 206 210 213
Choice 2000 Silver* Silver $115 181 181 181 181 182 185 190 197 203 205 210 214 217 220 221 223 224 226 228 231 236 240
Choice 4000 Silver Silver $107 169 169 169 169 170 173 177 184 189 192 196 200 202 205 207 208 209 211 213 216 220 224
Connect 2000 Silver* Silver $105 166 166 166 166 167 170 174 180 186 188 192 196 199 202 203 204 206 207 209 212 216 220
Connect 4000 Silver Silver $98 155 155 155 155 156 159 162 168 173 176 180 183 186 188 189 191 192 193 196 198 202 205
Providence Oregon* Standard Gold Plan Gold $136 214 214 214 214 215 219 224 233 239 243 248 253 256 260 262 263 265 267 270 273 279 284
Providence Oregon* Standard Silver Plan Silver $116 183 183 183 183 184 187 192 199 205 208 212 216 219 222 224 225 227 228 231 234 238 242
Providence Oregon* Standard Bronze Plan Bronze $98 154 154 154 154 155 158 161 167 172 175 178 182 184 187 188 189 191 192 194 197 201 204
Providence Essential* Catastrophic $94 148 148 148 148 149 152 155 161 166 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Group A counties:
Clackamas, Multnomah, Washington, Yamhill*
*Connect plans are not available for purchase in Yamhill county.
24 25
Individual and Family Plan Rates, Group A: Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 289 298 308 320 333 349 364 381 398 417 436 455 476 498 520 543 556 580 600 613 630 640
Balance 4000 Silver Silver 272 279 289 300 312 328 341 358 373 391 408 428 447 468 488 510 521 543 562 575 591 601
HSA Qualified 2800 Bronze Bronze 240 248 255 266 277 289 303 317 330 345 361 378 395 414 431 451 461 481 497 509 523 531
Choice 2000 Silver* Silver 271 278 287 299 311 326 340 355 372 388 406 425 444 464 485 507 518 540 560 572 587 597
Choice 4000 Silver Silver 252 260 268 279 290 304 317 332 347 363 380 397 415 433 453 474 484 505 523 535 549 558
Connect 2000 Silver* Silver 248 255 264 274 285 298 311 326 341 356 373 389 407 426 446 465 475 496 513 525 539 548
Connect 4000 Silver Silver 231 239 246 256 266 278 290 305 318 333 348 364 381 398 416 435 443 463 480 490 504 512
Providence Oregon* Standard Gold Plan Gold 319 329 340 353 367 385 402 420 439 460 481 503 525 549 574 600 613 639 661 677 695 706
Providence Oregon* Standard Silver Plan Silver 273 282 290 303 315 329 343 360 375 393 410 430 449 470 491 513 524 547 565 579 594 604
Providence Oregon* Standard Bronze Plan Bronze 230 237 244 254 265 277 289 303 316 331 345 362 377 395 413 431 441 460 476 486 501 508
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $135 213 213 213 213 215 219 223 232 239 242 248 253 255 260 261 263 264 266 270 273 278 283
Balance 4000 Silver Silver $128 200 200 200 200 201 205 210 218 224 228 232 237 240 243 244 246 248 250 253 256 261 265
HSA Qualified 2800 Bronze Bronze $112 177 177 177 177 178 182 186 193 198 201 206 209 212 215 217 218 219 221 223 227 231 234
Choice 2000 Silver* Silver $127 199 199 199 199 200 204 209 217 223 226 231 235 239 242 243 245 246 249 251 254 260 264
Choice 4000 Silver Silver $118 186 186 186 186 187 190 195 202 208 211 216 220 222 226 228 229 230 232 234 238 242 246
Connect 2000 Silver* Silver $116 183 183 183 183 184 187 191 198 205 207 211 216 219 222 223 224 227 228 230 233 238 242
Connect 4000 Silver Silver $108 171 171 171 171 172 175 178 185 190 194 198 201 205 207 208 210 211 212 216 218 222 226
Providence Oregon* Standard Gold Plan Gold $150 235 235 235 235 237 241 246 256 263 267 273 278 282 286 288 289 292 294 297 300 307 312
Providence Oregon* Standard Silver Plan Silver $128 201 201 201 201 202 206 211 219 226 229 233 238 241 244 246 248 250 251 254 257 262 266
Providence Oregon* Standard Bronze Plan Bronze $108 169 169 169 169 171 174 177 184 189 193 196 200 202 206 207 208 210 211 213 217 221 224
Providence Essential* Catastrophic $103 163 163 163 163 164 167 171 177 183 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.
Group A counties:
Clackamas, Multnomah, Washington, Yamhill*
*Connect plans are not available for purchase in Yamhill county.
26 27
Individual and Family Plan Rates, Group B: Non-Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Group B counties:
Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 271 279 289 300 312 327 341 357 373 390 408 427 446 466 487 509 520 542 561 574 590 600
Balance 4000 Silver Silver 254 262 271 281 293 306 320 335 350 366 382 400 418 437 457 478 488 509 527 539 553 561
HSA Qualified 2800 Bronze Bronze 225 232 239 249 259 271 283 296 309 324 338 354 370 387 404 423 432 450 466 476 490 498
Choice 2000 Silver* Silver 253 260 269 280 291 305 318 333 348 364 380 398 416 435 454 475 485 506 524 536 550 558
Choice 4000 Silver Silver 236 243 251 261 272 285 297 311 325 340 355 372 388 406 424 444 453 472 489 500 514 522
Connect 2000 Silver* Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Providence Oregon* Standard Gold Plan Gold 299 308 318 331 345 360 376 394 411 430 450 471 492 514 537 562 574 598 619 633 651 660
Providence Oregon* Standard Silver Plan Silver 256 263 272 283 295 308 322 337 352 368 385 402 420 440 459 480 491 512 530 542 556 564
Providence Oregon* Standard Bronze Plan Bronze 215 222 229 238 248 259 271 283 296 310 324 339 354 370 387 404 413 430 446 456 468 477
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $127 200 200 200 200 201 205 209 217 224 227 232 236 239 243 244 246 247 249 252 255 260 265
Balance 4000 Silver Silver $119 187 187 187 187 188 192 196 204 210 213 217 222 225 228 229 231 232 234 237 240 244 248
HSA Qualified 2800 Bronze Bronze $105 166 166 166 166 166 170 174 180 186 188 192 196 199 201 203 204 205 207 209 212 216 220
Choice 2000 Silver* Silver $118 186 186 186 186 187 191 195 203 209 212 216 221 223 226 228 229 231 232 235 238 243 247
Choice 4000 Silver Silver $111 174 174 174 174 175 178 182 189 195 198 202 206 209 211 213 214 215 217 220 222 227 231
Connect 2000 Silver* Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Providence Oregon* Standard Gold Plan Gold $140 220 220 220 220 221 226 231 240 247 250 255 261 264 268 269 271 273 275 278 282 287 292
Providence Oregon* Standard Silver Plan Silver $120 188 188 188 188 189 193 198 205 211 214 218 223 226 229 230 232 233 235 238 241 245 250
Providence Oregon* Standard Bronze Plan Bronze $101 159 159 159 159 159 162 166 172 177 180 184 188 190 193 194 195 196 198 200 203 207 210
Providence Essential* Catastrophic $97 152 152 152 152 153 156 160 166 171 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
28 29
Individual and Family Plan Rates, Group B: Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Group B counties:
Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk
Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 298 307 318 330 343 360 375 393 410 429 449 470 491 513 536 560 572 596 617 631 649 660
Balance 4000 Silver Silver 279 288 298 309 322 337 352 369 385 403 420 440 460 481 503 526 537 560 580 593 608 617
HSA Qualified 2800 Bronze Bronze 248 255 263 274 285 298 311 326 340 356 372 389 407 426 444 465 475 495 513 524 539 548
Choice 2000 Silver* Silver 278 286 296 308 320 336 350 366 383 400 418 438 458 479 499 523 534 557 576 590 605 614
Choice 4000 Silver Silver 260 267 276 287 299 314 327 342 358 374 391 409 427 447 466 488 498 519 538 550 565 574
Connect 2000 Silver* Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Providence Oregon* Standard Gold Plan Gold 329 339 350 364 380 396 414 433 452 473 495 518 541 565 591 618 631 658 681 696 716 726
Providence Oregon* Standard Silver Plan Silver 282 289 299 311 325 339 354 371 387 405 424 442 462 484 505 528 540 563 583 596 612 620
Providence Oregon* Standard Bronze Plan Bronze 237 244 252 262 273 285 298 311 326 341 356 373 389 407 426 444 454 473 491 502 515 525
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $140 220 220 220 220 221 226 230 239 246 250 255 260 263 267 268 271 272 274 277 281 286 292
Balance 4000 Silver Silver $131 206 206 206 206 207 211 216 224 231 234 239 244 248 251 252 254 255 257 261 264 268 273
HSA Qualified 2800 Bronze Bronze $116 183 183 183 183 183 187 191 198 205 207 211 216 219 221 223 224 226 228 230 233 238 242
Choice 2000 Silver* Silver $130 205 205 205 205 206 210 215 223 230 233 238 243 245 249 251 252 254 255 259 262 267 272
Choice 4000 Silver Silver $122 191 191 191 191 193 196 200 208 215 218 222 227 230 232 234 235 237 239 242 244 250 254
Connect 2000 Silver* Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Providence Oregon* Standard Gold Plan Gold $154 242 242 242 242 243 249 254 264 272 275 281 287 290 295 296 298 300 303 306 310 316 321
Providence Oregon* Standard Silver Plan Silver $132 207 207 207 207 208 212 218 226 232 235 240 245 249 252 253 255 256 259 262 265 270 275
Providence Oregon* Standard Bronze Plan Bronze $111 175 175 175 175 175 178 183 189 195 198 202 207 209 212 213 215 216 218 220 223 228 231
Providence Essential* Catastrophic $107 167 167 167 167 168 172 176 183 188 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
30 31
Individual and Family Plan Rates, Group C: Non-Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Group C counties:
Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 308 317 328 340 355 371 387 405 423 443 463 485 506 530 553 578 591 616 638 652 670 681
Balance 4000 Silver Silver 289 297 307 319 333 348 363 380 397 416 434 455 475 497 519 543 554 578 598 612 629 639
HSA Qualified 2800 Bronze Bronze 256 263 272 283 294 308 321 336 351 368 384 402 420 439 459 480 490 511 529 541 556 564
Choice 2000 Silver* Silver 287 296 306 318 331 346 361 378 395 413 432 452 472 494 516 540 551 575 595 608 625 636
Choice 4000 Silver Silver 268 276 286 297 309 323 337 353 369 386 403 422 441 461 482 504 515 537 556 568 584 594
Connect 2000 Silver* Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Providence Oregon* Standard Gold Plan Gold 340 350 362 376 391 409 427 447 467 489 511 535 558 584 610 638 652 680 704 719 739 750
Providence Oregon* Standard Silver Plan Silver 291 299 309 321 335 350 365 382 399 418 437 457 477 500 522 546 557 581 602 615 632 642
Providence Oregon* Standard Bronze Plan Bronze 245 252 260 270 282 295 307 322 336 352 368 385 402 420 439 459 469 489 506 518 532 540
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $144 227 227 227 227 228 232 238 247 254 258 263 269 272 276 277 279 281 283 286 290 296 301
Balance 4000 Silver Silver $135 213 213 213 213 214 218 223 231 238 242 247 252 255 259 260 262 264 265 269 272 277 282
HSA Qualified 2800 Bronze Bronze $120 188 188 188 188 189 193 197 205 211 214 218 223 226 229 230 232 233 235 238 241 245 250
Choice 2000 Silver* Silver $134 212 212 212 212 213 217 222 230 237 240 245 251 254 257 259 260 262 264 267 271 276 281
Choice 4000 Silver Silver $126 198 198 198 198 199 202 207 215 221 224 229 234 237 240 242 243 245 246 250 253 257 262
Connect 2000 Silver* Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ——————————————————————— Not available in these counties ———————————————————————
Providence Oregon* Standard Gold Plan Gold $159 250 250 250 250 251 256 262 272 280 284 290 296 300 304 306 308 310 312 316 320 326 332
Providence Oregon* Standard Silver Plan Silver $136 214 214 214 214 215 219 224 233 240 243 248 253 257 260 262 263 265 267 270 274 279 284
Providence Oregon* Standard Bronze Plan Bronze $114 180 180 180 180 181 185 189 196 202 205 209 213 216 219 220 222 223 225 227 230 235 239
Providence Essential * Catastrophic $110 173 173 173 173 174 177 181 188 194 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
32 33
Individual and Family Plan Rates, Group C: Tobacco UserPurchase any of these plans directly from Providence at www.ProvidenceHealthPlan.com or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov.
Effective Jan. 1, 2015 – Dec. 31, 2015
Group C counties:
Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.
Metal Level 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Over
Balance 2000 Silver Silver 339 349 361 374 391 408 426 446 465 487 509 534 557 583 608 636 650 678 702 717 737 749
Balance 4000 Silver Silver 318 327 338 351 366 383 399 418 437 458 477 501 523 547 571 597 609 636 658 673 692 703
HSA Qualified 2800 Bronze Bronze 282 289 299 311 323 339 353 370 386 405 422 442 462 483 505 528 539 562 582 595 612 620
Choice 2000 Silver* Silver 316 326 337 350 364 381 397 416 435 454 475 497 519 543 568 594 606 633 655 669 688 700
Choice 4000 Silver Silver 295 304 315 327 340 355 371 388 406 425 443 464 485 507 530 554 567 591 612 625 642 653
Connect 2000 Silver* Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Providence Oregon* Standard Gold Plan Gold 374 385 398 414 430 450 470 492 514 538 562 589 614 642 671 702 717 748 774 791 813 825
Providence Oregon* Standard Silver Plan Silver 320 329 340 353 369 385 402 420 439 460 481 503 525 550 574 601 613 639 662 677 695 706
Providence Oregon* Standard Bronze Plan Bronze 270 277 286 297 310 325 338 354 370 387 405 424 442 462 483 505 516 538 557 570 585 594
Providence Essential* Catastrophic ——————————————————————————————————————— ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
Metal Level 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Balance 2000 Silver Silver $158 250 250 250 250 251 255 262 272 279 284 289 296 299 304 305 307 309 311 315 319 326 331
Balance 4000 Silver Silver $149 234 234 234 234 235 240 245 254 262 266 272 277 281 285 286 288 290 292 296 299 305 310
HSA Qualified 2800 Bronze Bronze $132 207 207 207 207 208 212 217 226 232 235 240 245 249 252 253 255 256 259 262 265 270 275
Choice 2000 Silver* Silver $147 233 233 233 233 234 239 244 253 261 264 270 276 279 283 285 286 288 290 294 298 304 309
Choice 4000 Silver Silver $139 218 218 218 218 219 222 228 237 243 246 252 257 261 264 266 267 270 271 275 278 283 288
Connect 2000 Silver* Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Connect 4000 Silver Silver ——————————————————————————————————————— ————————————————————— Not available in these counties —————————————————————
Providence Oregon* Standard Gold Plan Gold $175 275 275 275 275 276 282 288 299 308 312 319 326 330 334 337 339 341 343 348 352 359 365
Providence Oregon* Standard Silver Plan Silver $150 235 235 235 235 237 241 246 256 264 267 273 278 283 286 288 289 292 294 297 301 307 312
Providence Oregon* Standard Bronze Plan Bronze $125 198 198 198 198 199 204 208 216 222 226 230 234 238 241 242 244 245 248 250 253 259 263
Providence Essential * Catastrophic $121 190 190 190 190 191 195 199 207 213 ——————————————————— Not available to people age 30 and older ———————————————————
AgeAge
34 35
Decision worksheet
Use this worksheet to compare plans and determine your monthly premium. There is no additional cost for more than three children ages 0-20.
Monthly premium
Monthly premium
Monthly premium
Subscriber Subscriber Subscriber
Spouse Spouse Spouse
Child #1 Child #1 Child #1
Child #2 Child #2 Child #2
Child #3 Child #3 Child #3
Total premium Total premium Total premium
Plan name Plan name Plan name
Pros Pros Pros
Cons Cons Cons
Notes:
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With all of the options you have, choosing a new health plan could be challenging, to say the least. Here is a step-by-step guide to help you make the right decision for yourself and your family.
Step 1: Review your current plan. What do you like about it? What aspects of your current plan do you definitely want to keep in your new plan? Make a list to refer to as you review your new plan options.
Step 2: Think about your health care needs for 2015. How many doctor visits, aside from preventive care, do you anticipate needing? Do you want to keep your current providers? Are you planning any surgeries? Do you need new eyeglasses?
Step 3: Decide what type of provider network you prefer.
• Do you want the freedom to choose from nearly 1 million providers nationwide? If so, consider a Providence Balance, HSA, Standard or Essential plan. (Essential plan is available only to people age 29 and younger)
• Would you prefer to work closely with a care team from one medical home, with the flexibility for specialist referrals? If so, consider a Providence Choice plan.
• Would you rather have a care team from one medical home in the Portland metro area to support every aspect of your health and wellness? If so, consider a Providence Connect plan.
Step 4: Determine your budget. What can your budget handle for monthly premiums and out-of-pocket costs? Review the benefit summary and rate charts to compare benefits and premiums. Shop now at www.ProvidenceHealthPlan.com to review side-by-side comparisons of benefits, rates and networks.
Step 5: Find out if you are eligible for financial assistance. Use the calculator at www.HealthCare.gov to determine the exact amount of any tax credit or cost-sharing subsidy you may be eligible for. If you are eligible, you must complete the steps on the Marketplace website at www.HealthCare.gov to receive your tax credit or subsidy.
Step 6: Choose your new plan. Be sure to specify which Providence plan you’ve chosen if you shop on the Marketplace website.
Questions? Call a Providence representative at 503-574-5000 or 800-988-0088 TTY: 711, Monday through Friday, 8 a.m. to 8 p.m.
Decision-Making Guide
Providence Health & Services, a not-for-profit health system, is an equal-opportunity organization in the provision of health care services and employment opportunities.
© 2014 Providence Health Plan. All rights reserved.
Our Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.
Our Core Values Respect, Compassion, Justice, Excellence, Stewardship
Portland Metro Area 503-574-5000 All other areas 800-988-0088
Monday – Friday, 8 a.m. to 8 p.m.
www.ProvidenceHealthPlan.com
IND-016N (11/14)_OR14-02143
