Options and Information
2021 OKLAHOMA HEALTH PLANS PORTFOLIO
INDIVIDUAL & FAMILY HEALTH PLANS
PERSONALIZED COVERAGE YOU CAN TRUST.
As a Midwestern, not-for-profit health insurance plan, we’ve been putting the needs of our members at the forefront of everything we do for nearly 45 years. Take comfort in knowing Medica is on your side. We know you want affordability and options. Medica plans are designed to let you personalize your coverage to meet your unique needs and preferences. Take a look through our entire portfolio of Oklahoma offerings — you’ll discover that you can find your fit with Medica.
QUESTIONS? WE’RE HERE TO HELP.
Call Connect with a Medica Sales Consultant at (855) 347-5009 (TTY: 711 ).
Email Chat with a Medica Sales Consultant at MedicaIndividualProducts@Medica.com .
Find Look for an agent or broker in your community at Medica.com/Agent .
STEPS TO PERSONALIZING YOUR COVERAGE
Determine what’s available where you live. Not all health plans are available in all areas.
Understand your network options. This is who and where your care comes from.
Choose your plan type. Decide if you want a copay, value, share, or health savings account (HSA) compatible plan. Cost share reduction and catastrophic plans may also be available for those who qualify. To review benefits, check the product's Side-by-Side Comparison brochure. Choose individual or family coverage. You decide how to cover your family — whether that’s individual coverage for each family member — or a shared family plan.
WHERE YOU LIVE DETERMINES WHAT’S AVAILABLE TO YOU.
Balance by Medica SM Delivered by Mercy Balance Network: Available in Canadian, Logan and Oklahoma counties.
Harmony by Medica SM Harmony Network: Available in Adair, Atoka, Beckham, Canadian, Cherokee, Cleveland, Comanche, Cotton, Creek, Delaware, Garfield, Grady, Greer, Jackson, Jefferson, Logan, McClain, Nowata, Oklahoma, Ottawa, Pittsburg, Pottawatomie, Rogers, Stephens, Tulsa, Wagoner and Washington counties. Medica Quest SM Quest Network: Available in Alfalfa, Beaver, Blaine, Bryan, Caddo, Carter, Choctaw, Cimarron, Coal, Craig, Custer, Dewey, Ellis, Garvin, Grant, Harmon, Harper, Haskell, Hughes, Johnston, Kay, Kingfisher, Kiowa, Latimer, Le Flor, Lincoln, Love, McCurtain, McIntosh, Major, Marshall, Mayes, Murray, Muskogee, Noble, Okfuskee, Oklahoma, Osage, Pawnee, Payne, Pontotoc, Pottawatomie, Pushmataha, Roger Mills, Seminole, Sequoyah, Texas, Tillman, Washita, Woods and Woodward counties.
UNDERSTAND YOUR NETWORK This is who and where your care comes from. We offer a broad network that will give you access to a large number of providers. Or, local care-system networks that will provide you with significant cost savings. It's important to confirm your providers are in your plan's network.
CARE SYSTEM PROVIDER NETWORK OPTIONS These networks are localized, but the benefits are significant.
Balance by Medica SM Delivered by Mercy (Balance Network)
AVAILABILITY For individuals and families living in the Oklahoma City metro. Available in Canadian, Logan and Oklahoma counties.
NETWORK DETAILS Access to Mercy doctors, clinics and hospitals plus others. The network includes: 5,500+ Primary and specialty care providers 21+ Hospitals
Featured health care systems: Mercy Oklahoma Heart Hospital OU Medicine SEARCH THE NETWORK
WHERE CAN YOU GET CARE Oklahoma and parts of bordering states.
To view what health care systems and other providers are in the Balance Network, use the online search tool at Medica.com/SearchBalance .
Harmony by Medica SM (Harmony Network)
AVAILABILITY For individuals and families living in select Oklahoma counties.. Available in Adair, Atoka, Beckham, Canadian, Cherokee, Cleveland, Comanche, Cotton, Creek, Delaware, Garfield, Grady, Greer, Jackson, Jefferson, Logan, McClain, Nowata, Oklahoma, Ottawa, Pittsburg, Pottawatomie, Rogers, Stephens, Tulsa, Wagoner and Washington. counties.
NETWORK DETAILS Access to Ascension St. John and SSM Health doctors, clinics and hospitals plus others. The network includes: 7,000+ Primary and specialty care providers 40+ Hospitals
Featured health care systems: Ascension St. John Atoka County Medical Center Comanche County Memorial Hospital Duncan Regional Hospital Grady Memorial Hospital Great Plains Regional Medical Center INTEGRIS Health
WHERE CAN YOU GET CARE Oklahoma City and Tulsa metro — plus other communities across Oklahoma.
Jackson County Memorial Hospital McAlester Regional Health Center Norman Regional Health System Northeastern Health System OU Medicine | Medical Center & Children’s Hospital SSM Health SEARCH THE NETWORK To view what health care systems and other providers are in the Harmony Network, use the online search tool at Medica.com/SearchHarmony .
BROAD PROVIDER NETWORK OPTION This network provides access to a large number of providers.
Medica Quest SM (Quest Network)
AVAILABILITY For individuals and families living in select Oklahoma counties. Available in Alfalfa, Beaver, Blaine, Bryan, Caddo, Carter, Choctaw, Cimarron, Coal, Craig, Custer, Dewey, Ellis, Garvin, Grant, Harmon, Harper, Haskell, Hughes, Johnston, Kay, Kingfisher, Kiowa, Latimer, Le Flor, Lincoln, Love, McCurtain, McIntosh, Major, Marshall, Mayes, Murray, Muskogee, Noble, Okfuskee, Oklahoma, Osage, Pawnee, Payne, Pontotoc, Pottawatomie, Pushmataha, Roger Mills, Seminole, Sequoyah, Texas, Tillman, Washita, Woods and Woodward counties
NETWORK DETAILS Access to doctors, clinics and hospitals at many health care systems. The network includes: 12,000+ Primary and specialty care providers 80+ Hospitals SEARCH THE NETWORK To view what health care systems and other providers are in the Quest Network, use the online search tool at Medica.com/SearchQuest .
WHERE CAN YOU GET CARE Oklahoma and parts of bordering states.
YOUR CARE IS ALWAYS ACCESSIBLE Whether you choose a broad or local care system network, your care is always accessible. So you can get the care you need, when you need it. Your network will provide access to:
Primary Care For wellness check-ups and common illnesses. This includes Family Medicine, Internal Medicine, Pediatrics, and OBGYN services.
Specialty Care For advanced medical care and treatment of specific health conditions.
Convenience Care For fast, convenient same-day care of minor illnesses or injuries. No appointment needed.
Virtual or Telehealth Care Primary and specialty care through phone or online virtual visits.
Urgent Care For illness or injuries that need to be treated right away, but are not emergencies (life threatening).
Emergency Care For emergency or critical situations. Available 24/7.
CHOOSE YOUR PLAN Medica believes it's important for you to have a plan that fits you. So you can choose from a variety of plan designs. This determines how you and your health plan share the cost of your care. Here are the key features of each. Learn more about the plan options available to you in the Side-by-Side Comparison brochures.
PLAN TYPES FOR INDIVIDUALS & FAMILIES
You only pay a copay for office visits and prescription drugs. Other services you pay your share of the care costs until you satisfy your out-of-pocket maximum.
Metal Levels: 9 9 Gold 9 9 Silver 9 9 Bronze
Metal Levels: 9 9 Bronze
You only pay a copay for prescription drugs. Other services you pay your share of the care costs until you satisfy your out-of-pocket maximum.
Metal Levels: 9 9 Gold 9 9 Silver 9 9 Bronze
You pay your share of the care costs until you satisfy your out-of-pocket maximum. These plans can be paired with an HSA — which is a special savings account for medical costs.
Metal Levels: 9 9 Bronze
You only pay for the first three primary care office visits. Other services you pay your share of the care costs until you satisfy your out-of-pocket maximum. Available only to those under age 30 or with a hardship exemption.
*Not all plans are available with each product. Actual costs will vary based on plan and usage.
THERE’S HELP TO PAY FOR YOUR INSURANCE
Two kinds of help are available. Your estimated household income and other household information determine what you qualify for. You may find that with help, most or even all of your health care costs are covered.
PREMIUM TAX CREDITS You can use a tax credit to lower your monthly premium. This is what you pay each month for your insurance.
COST-SHARING This helps cover the costs of the care you receive. Cost-sharing is what you pay for the care covered by your plan. If you qualify, you must enroll in a plan in the Silver category. Members of federally recognized tribes may qualify for additional cost-sharing reductions (not shown in this brochure).
CHECK TO SEE WHAT YOU QUALIFY FOR If your estimated income is between 100-400% of the federal poverty level for your household size, you may qualify for a tax credit. Below are general guidelines that qualify for help*.
INDIVIDUALS With an income below $51,040
COUPLES With a household income below $68,960
FOUR-PERSON FAMILY With a household income below $104,800
PRESCRIPTION DRUG COVERAGE Our plans include a range of convenient services and options for filling and managing your prescriptions. Here are some features to keep in mind.
Medica's List of Covered Drugs To help keep your share of the costs at their lowest, our plans cover drugs on Medica's List of Covered Drugs . The list includes drugs that provide the most value and have proven safety and effectiveness. Your cost will vary depending on which tier your drug belongs to.
TIER DRUG TYPE
5 Non-Preferred Specialty 4 Preferred Specialty 3 Non-Preferred Brand 2 Preferred Brand 1 Generic
Network Pharmacy For your plan to cover a drug on the drug list, you need to visit a network pharmacy. Our pharmacy network includes more than 68,000 pharmacies nationwide including most major chains and thousands of independent pharmacies. 90-Day Refill Option You can get a 90-day supply of a drug that you take regularly. Pick it up at a network pharmacy — or have it sent through the mail, with no shipping or handling fees.
Insulin Coverage You'll pay no more than $25 for insulin per prescription unit when filled at a network pharmacy.
Search the Drug List or Find a Pharmacy To see what drugs are covered or to find a network pharmacy, use the online search tool at Medica.com/Plans4OK .
EXTRAS TO MAKE YOUR PLAN EVEN BETTER
A great plan is only one piece of the puzzle when it comes to maintaining your health. So we provide you with the extra resources you need to stay healthy each and every day.
Your Own Personal Health Advocate
Advocates are available to help you find doctors, estimate costs, and help you make informed health care decisions. This service is confidential — and provided at no additional cost.
No Cost Preventive Care All plans provide access to preventive care services at no cost. This includes exams, screenings, immunizations and more that can help avoid health problems or catch them early.
Healthy Pregnancy Support Tap into personalized guidance, support and coaching for your entire parenthood journey. This extra gives you on-demand support and clinically backed guidance to help you achieve your health goals, whether that's tracking your period, getting pregnant or navigating pregnancy, postpartum and parental wellness. This service is provided at no additional cost.
Online Health Program with Reward Opportunities
You'll have access to online programs to motivate and support you in maintaining a healthy lifestyle. Stay active, eat healthy, manage stress and find direction for your life. Plus, as you participate, you earn hearts that can be entered into reward drawings. This service is provided at no additional cost.
Complex Specialty Care Program Receive care for transplants, certain rare cancers and other complex specialty care at Mayo Clinic. An allowance for transportation, lodging and living expenses is also included. Before you use the program, you need a referral from your network doctor and approval from Medica.
24/7 NurseLine Trusted support for non-urgent care questions 24/7. Nurses are available to help answer your questions about symptoms, medications and health conditions, and offer self-care tips. They can even help you determine the best location for accessing care. This service is provided at no additional cost.
There are two enrollment periods when you can buy a plan:
Open Enrollment Period The period each year anyone can enroll in a plan. For coverage that starts in 2021, this period is November 1 through December 15, 2020. Special Enrollment Period A 60-day period outside of the Open Enrollment Period when you can enroll in a plan. You only qualify if you experience certain life events like getting married, losing coverage, moving, having a baby, or adopting a child.
READY TO ENROLL?
Gather this information for each person applying before you start your application: o o Social Security number and date of birth (everyone in the household, not just those applying) o o Current insurance information
o o Payment information o o Tobacco use status
Applying on the Health Insurance Marketplace (HealthCare.gov)? Gather this information, too.
o o Driver's license, Tribal ID, Green Card or other ID o o Last year's tax forms (1040EZ or 1040) o o Two most recent pay stubs o o Documents for other sources of income (social security, unemployment, self-employment, etc.) o o W2 form or Employer Tax ID Number
THERE ARE THREE EASY WAYS TO SIGN UP:
HEALTH INSURANCE MARKETPLACE
OVER THE PHONE
To apply with financial assistance, visit healthcare.gov . Then, follow these steps:
Call (855) 347-5009 (TTY: 711 ). A Medica Sales Consultant can help you shop, compare plans and enroll in coverage over the phone.
Create or log in to your account If you’re a new user, you’ll need to create an account and provide some basic demographic information. Returning user? Log in to your account and select your 2020 application. Then, follow the steps to update and confirm your information. Review your Eligibility Determination After you submit your information, you’ll receive your Eligibility Determination . Your results will highlight if you’re eligible for a tax credit to lower your monthly premiums and out-of-pocket costs. If eligible, it will show you how much you can save. Pick your plan Next, you’ll see all the health insurance plans available in your area. Enroll in your plan Select your preferred plan and follow the steps to enroll.
WITH YOUR AGENT
If you work with a licensed agent, they're your best resource to help you make your plan selection and enroll in coverage.
Working with a sales consultant or agent to complete your application? Make sure you include their agent (NPN) number on your application.
WHAT TO EXPECT AFTER ENROLLMENT
What's next after you enroll in Medica coverage online, with your agent or over the phone? Here's a quick summary of the materials you'll receive from us so you can start using your plan.
What Medica is doing:
Reviewing your application and setting up your policy. We’ll contact you if we need more information.
Creating your ID card. You'll receive your card 7-10 days after we process your first month's premium payment.
Building your Welcome Kit. You'll receive your kit 7-10 days after we process your first month's premium payment. It includes information to help you get the most from your plan.
What you can do:
Pay your first month's premium. To activate your coverage, you must make your payment. You have two options: »» Pay online. Visit Medica.com/FirstPayment to pay electronically with your bank account or credit card. »» Mail your payment. We'll send you a pending payment letter with instructions on how to send in your payment. Register for your secure member site. After you receive your ID card and your coverage starts, visit MedicaMember.com to register. This website is your one-stop resource for the information you need to manage your health plan benefits and help improve your health. »» View your ID card. »» See what's covered by your plan, including important plan documents. »» Track your plan balances, such as your deductible and out-of-pocket maximum. »» Track your claims and explanation of benefits (EOB). »» Look up prices for prescriptions. »» Wellness tools and support. »» Check to see if a doctor or other health care provider is in your plan's network. »» Pay your monthly premium.
OTHER IMPORTANT INFORMATION Eligibility and Requirements
Pediatric Dental is Not Covered These policies do not include pediatric dental services. Pediatric dental is an essential health benefit that can be purchased as a standalone product through the Health Insurance Marketplace. For more information visit healthcare.gov . Member Complex Case Management We have services and programs designed to help members with certain health conditions manage their overall care and treatment. Find more information about the programs and services available by visiting Medica.com/Plans4OK . Health Savings Account The Bronze HSA plan can be paired with a health savings account (HSA) — which is a special savings account for IRS-approved medical expenses. Generally, Cost Share Reduction (CSR) plans cannot be paired with an HSA. Learn more about the benefits of an HSA or how to open an account by visiting Medica.com/HSA .
To qualify for a Medica plan, you must be a resident of Oklahoma, and not eligible for or enrolled in Medicare. You also must live within your selected network’s service area to enroll in and remain in the plan. Understanding Benefits and Coverage Details This brochure is a brief overview of the plans. For complete benefit details, limitations, and exclusions please see a Medica Individual and Family insurance policy. This can be found by visiting Medica.com/ Plans4OK or request a paper copy by calling (855) 347-5009 (TTY: 711 ). Prior Approvals and Excluded Services Some services and procedures require prior approval from Medica before they are covered. Services not covered include, but are not limited to, custodial care, adult eyewear, most dental services, cosmetic services, refractive eye surgery, those received while on military duty and services that are investigational or not medically necessary. For a complete list, see a Medica Individual and Family insurance policy available on Medica.com/ Plans4OK or call (855) 347-5009 (TTY: 711 ).
Deductible and Out-Of-Pocket Maximum Details The deductible and out-of-pocket maximum are subject to a “cost of living” increase on a yearly basis. This increase is tied to the Consumer Price Index and/or may result from adjustments needed to keep plans within the range for a given metal level; metal levels (e.g., Gold, Silver, Bronze) must always be in compliance with the Affordable Care Act (ACA) for Qualified Health Plans (QHPs). The Marketplace and Cost Share Reduction Plans You may be able to receive help paying your health insurance premium or qualify for plans with reduced deductibles and copays. Plans with reduced deductibles and copays are called Cost Share Reduction (CSR) plans. You can get this assistance if you get health insurance through the Health Insurance Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. Reduced cost sharing is not available with a Catastrophic plan. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits. To see if you’re eligible, please visit healthcare.gov .
Medica Privacy Notice Medica takes its responsibility of protecting your personal information seriously. Where possible, Medica de-identifies or encrypts personal information. We use and disclose personal information only to the extent necessary to conduct treatment, payment and health care operations, or to comply with legal, regulatory or accreditation requirements. Medica’s full Privacy Notice is available upon request by calling (855) 347-5009 (TTY: 711 ) or by going to Medica.com/Privacy .
Call us at (855) 347-5009 (TTY: 711 ) Hours of operation: Monday – Thursday 8 a.m. to 5 p.m. Central Friday 10 a.m. to 5 p.m. Central Email us at: MedicaIndividualProducts@Medica.com
OKLAHOMA, WE’VE GOT YOU COVERED. SM
Visit us on the web: Medica.com/Plans4OK
Medica is a Qualified Health Plan issuer in the Health Insurance Marketplace. Balance by Medica SM , Harmony by Medica SM and Medica Quest SM are service marks of Medica Health Plans.
© 2020 Medica. Medica ® is a registered service mark of Medica Health Plans. "Medica" refers to the family of health plan businesses that includes Medica Health Plans, Medica Community Health Plan, Medica Insurance Company, Medica Self-Insured, MMSI, Inc. d/b/a Medica Health Plan Solutions, Medica Health Management, LLC and the Medica Foundation. All other trademarks are the property of their respective owners.
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