1. Healthcare

INDIVIDUALS & FAMILIES
2015 Plan Overview
Your partner in health and wellness
Choosing 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’re easy to work with.
• We offer a broad range of plan types
and cost-sharing options (e.g., deductible,
coinsurance and copayment).
• 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.
• Our networks range from a
local base of medical home
providers to nearly 1 million
providers nationwide.
• 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.
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.
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.
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
• 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
• Award-winning care managers who
provide education and support for chronic
conditions, such as asthma and diabetes
°° Email your PMG provider
• Health and wellness classes to help you
manage stress, achieve a healthy weight,
begin a yoga practice and more
°° Access your lab and test results
• 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
°° Pay bills online
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.
• We’re innovative. With telemedicine and close
coordination between our hospitals and clinics,
you get better care.
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Your lifestyle, your plan
Where to buy plans
Choose a 2015 health plan that best fits your life, and your health. You’ll find robust benefits
Purchase the right Providence plan for you at www.ProvidenceHealthPlan.com, or ask
and extensive provider choices; an HSA-qualified plan that lets you save tax-free dollars for
a Providence representative or your insurance producer for help. Providence plans are also
future medical expenses; and two plan types centered on a medical home model that lets
available through the Federal Health Insurance Marketplace at HealthCare.gov.
you choose a primary care clinic near you with a health care team to coordinate your care.
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.
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Clatsop
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Lincoln
Polk
an
Clackamas
Yamhill
Umatilla
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lam
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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 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.
Silver
•
Balance 4000 Silver
Silver
•
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
•
•
Bronze
•
•
Catastrophic
•
•
HSA Qualified 2800 Bronze
Wasco
Morrow
Union
Gilliam
Marion
Jefferson
Baker
Wheeler
Crook
Coos
Deschutes
Harney
Douglas
Josephine
Klamath
Jackson
•
Grant
Linn
Lane
•
Wallowa
Malheur
Providence Oregon Standard Bronze Plan
Providence Essential
Curry
Pediatric dental coverage
Balance 2000 Silver
Co
The Balance, Choice and Connect plans cover
chiropractic manipulation and acupuncture with a
$25 copay when you visit an in-network provider.
She
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.
Metal tier
There’s a Providence plan for you and your
family, no matter where you live in Oregon.
Benton
Alternative care options
Plans available from
the Federal Health
Insurance Marketplace
at HealthCare.gov
Plans available directly
from Providence or
your producer
Lake
Compare plans • Check rates • Apply and enroll online
Connect plans are available only in Multnomah,
Clackamas and Washington counties.
We can help you find the right plan. Apply and enroll:
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• Online at www.ProvidenceHealthPlan.com
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• Over the phone with a Providence representative
Multnomah
Clackamas
Yamhill
Hood
River
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
Polk
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Marion
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.
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Balance
Balance (continued)
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 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-ofpocket expense is your copay, where applicable
Providence EPO Network: A network of nearly
1 million health care providers nationwide, both
in Providence facilities and in other locations.
• A deductible you can apply to the
out-of-pocket maximum
Balance 2000 Silver
Balance 4000 Silver
in-network
out-of-network
in-network
out-of-network
Personal Physician/Provider
$25 ✓
50%
$25 ✓
50%
Specialist
$50 ✓
50%
$50 ✓
50%
Alternative care provider (e.g., naturopath,
chiropractor, acupuncturist)
$25 ✓
50%
$25 ✓
50%
30%
50%
30%
50%
Emergency services
$250 then 30%
$250 then 30%
$250 then 30%
$250 then 30%
Urgent care services
$75 ✓
50%
$75 ✓
50%
30% ✓
50%
30% ✓
50%
30%
50%
30%
50%
Inpatient and residential services
30%
50%
30%
50%
Outpatient provider visits
$25 ✓
50%
$25 ✓
50%
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%
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
OFFICE VISITS FOR MEDICAL SERVICES
HOSPITAL SERVICES
• Coverage for routine vision services,
including glasses and contacts
Inpatient hospital services and maternity care
EMERGENCY/URGENT CARE
• The freedom to choose any provider, in and
out of the Providence EPO Network
• Pediatric dental coverage
OUTPATIENT DIAGNOSTIC SERVICES
X-ray and lab services
High tech imaging services (such as PET, CT, MRI)
MENTAL HEALTH AND SUBSTANCE ABUSE
OTHER COVERED SERVICES
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
PRESCRIPTION DRUGS
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
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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%
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 ✓
$30 ✓
Covered ✓
$30 ✓
Covered ✓
Covered ✓
Covered ✓
Covered ✓
Covered ✓
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%
ADULT VISION SERVICES
Routine eye exams
(limited to one exam per calendar year)
Vision hardware
(frames, lenses, contact lenses) Limits apply
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings,
x-rays, topical fluoride, and sealants)
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HSA Qualified
HSA Qualified (continued)
These 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
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
Personal Physician/Provider
50%
50%
Specialist
50%
50%
Alternative care provider (e.g., naturopath, chiropractor,
acupuncturist)
50%
50%
50%
50%
Emergency services
50%
50%
Urgent care services
50%
50%
X-ray and lab services
50%
50%
• Pediatric dental coverage
High tech imaging services (such as PET, CT, MRI)
50%
50%
• A preferred rate and easy set-up when you open
a health savings account with HealthEquity®,
a partner of Providence Health Plan
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient and residential services
50%
50%
Outpatient provider visits
50%
50%
50%
50%
Not Covered
Not Covered
Generic
50%
Not Covered
Preferred brand name
50%
Not Covered
Non-preferred brand name and specialty
50%
Not Covered
savings account, you save pre-tax dollars to pay for future health care expenses.
OFFICE VISITS FOR MEDICAL SERVICES
HSA Qualified plans offer:
• Care from specialists without a referral
rovidence EPO Network: A network of nearly
P
1 million health care providers nationwide, both
in Providence facilities and in other locations.
• Lower premiums with most services
subject to the deductible
HOSPITAL SERVICES
• In-network preventive care and adult routine vision
services that are covered before the deductible
Inpatient hospital services and maternity care
EMERGENCY/URGENT CARE
• The freedom to choose any provider, in
or out of the Providence EPO Network
• A deductible that applies to the
out-of-pocket maximum
OUTPATIENT DIAGNOSTIC SERVICES
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or
hospital-based facility
Chiropractic manipulation and acupuncture
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 ✓
PRESCRIPTION DRUGS
HSA Qualified 2800 Bronze
in-network
out-of-network
Annual Deductible Individual/Family
$2,800/$5,600
$5,600/$11,200
Routine eye exams (limited to one exam per calendar year)
Covered in full ✓
Covered ✓
Annual Out-of-Pocket Maximum
Individual/Family
$6,200/$12,400
$12,400/$24,800
Vision hardware (frames, lenses, contact lenses) Limits apply
Covered in full ✓
Covered ✓
$25 ✓
Covered ✓
Not Covered
Not Covered
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%
ADULT VISION SERVICES
PREVENTIVE CARE
8
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
Routine eye exams (limited to one exam per calendar year)
Periodic health exams and well-baby care (from any provider
licensed to perform the service)
Covered in full ✓
50%
Vision hardware (frames, lenses, contact lenses) Limits apply
Maternity prenatal care
Covered in full ✓
50%
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Gynecological exams; Pap tests
Covered in full ✓
50%
Mammograms
Covered in full ✓
50%
Preventive services (routine exams, cleanings,
x-rays, topical fluoride, and sealants)
Colorectal cancer screenings (age 50 and over)
Covered in full ✓
50%
9
Choice
Choice (continued)
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 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
from wellness and prevention to active management of chronic conditions.
Providence Choice Network: A network of over 200
primary care clinics located throughout Oregon and
southwest Washington designated as medical homes
Wahkiakum
Cowlitz
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Klickitat
Clark
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Wasco
Wallowa
Morrow
Union
Gilliam
Marion
Jefferson
Benton
• 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
Umatilla
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Clackamas
Yamhill
Polk
She
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lam
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Baker
Wheeler
Grant
Linn
Personal Physician/Provider
$25 ✓
50%
$25 ✓
50%
Specialist
$50 ✓
50%
$50 ✓
50%
Alternative care provider (e.g., naturopath,
chiropractor, acupuncturist)
$25 ✓
50%
$25 ✓
50%
30%
50%
30%
50%
Emergency services
$250 then 30%
$250 then 30%
$250 then 30%
$250 then 30%
Urgent care services
$75 ✓
50%
$75 ✓
50%
30% ✓
50%
30% ✓
50%
30%
50%
30%
50%
Inpatient and residential services
30%
50%
30%
50%
Outpatient provider visits
$25 ✓
50%
$25 ✓
50%
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%
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
HOSPITAL SERVICES
Coos
X-ray and lab services
Harney
Douglas
High tech imaging services (such as PET, CT, MRI)
Malheur
MENTAL HEALTH AND SUBSTANCE ABUSE
Josephine
Jackson
Klamath
Lake
For a complete list of medical homes
and providers by location, visit
www.ProvidenceHealthPlan.com/providerdirectory.
• Pediatric dental coverage
• Adult vision coverage (exams and hardware)
OTHER COVERED SERVICES
PRESCRIPTION DRUGS
Choice
Choice 2000 Silver
Choice 4000 Silver
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
in-network
out-ofnetwork
in-network
out-ofnetwork
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
The deductible is waived for all covered services required to treat an
accidental injury within 90 days of injury.
PREVENTIVE CARE
10
out-ofnetwork
OUTPATIENT DIAGNOSTIC SERVICES
Deschutes
Curry
• Separate deductibles and out-of-pocket
maximums in and out of the network
Accidental Injury Benefit
in-network
Crook
Lane
• Higher cost shares for select services
such as knee and hip replacement,
sleep studies, and sinus surgery
After meeting your deductible, you pay the
following amounts for covered services.
The deductible is waived for some covered
services. These are marked with ✓
out-ofnetwork
EMERGENCY/URGENT CARE
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• Access a broad network of specialists and facilities
via referral from the medical home in order to
receive coverage at the in-network level
in-network
Inpatient hospital services and maternity care
Skamania
• More than 200 medical home clinics in Oregon
and southwest Washington that provide a
patient-focused, coordinated care experience
Choice 4000 Silver
OFFICE VISITS FOR MEDICAL SERVICES
home team then works collaboratively to support all aspects of a member’s health,
Choice plans offer:
Choice 2000 Silver
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%
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 ✓
$30 ✓
Covered ✓
$30 ✓
Covered ✓
Covered ✓
Covered ✓
Covered ✓
Covered ✓
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%
ADULT VISION SERVICES
Routine eye exams (limited to one
exam per calendar year)
Vision hardware (frames, lenses,
contact lenses) Limits apply
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings,
x-rays, topical fluoride, and sealants)
11
Connect
Connect (continued)
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 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
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.
Providence Connect Network: A Portlandarea network of over 65 primary care clinics
in Multnomah, Washington and Clackamas
counties designated as medical homes.
• More than 65 medical home clinics
in the Portland metro area
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• No deductible for doctor and specialist visits,
lab and X-ray services, and generic drugs
$25 ✓
50%
$25 ✓
50%
Specialist
$50 ✓
50%
$50 ✓
50%
Alternative care provider (e.g., naturopath,
chiropractor, acupuncturist)
$25 ✓
50%
$25 ✓
50%
30%
50%
30%
50%
Emergency services
$250 then 30%
$250 then 30%
$250 then 30%
$250 then 30%
Urgent care services
$75 ✓
50%
$75 ✓
50%
30% ✓
50%
30% ✓
50%
Multnomah
30%
50%
30%
50%
Inpatient and residential services
30%
50%
30%
50%
Outpatient provider visits
$25 ✓
50%
$25 ✓
50%
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%
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
X-ray and lab services
Hood
River
High tech imaging services (such as PET, CT, MRI)
Polk
OTHER COVERED SERVICES
Marion
For a complete list of medical homes
and providers by location, visit
www.ProvidenceHealthPlan.com/providerdirectory.
Connect
Connect 2000 Silver
Connect 4000 Silver
in-network
out-ofnetwork
in-network
out-ofnetwork
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
The deductible is waived for all covered services required to treat an
accidental injury within 90 days of injury.
PREVENTIVE CARE
12
Personal Physician/Provider
OUTPATIENT DIAGNOSTIC SERVICES
Clackamas
Yamhill
• Higher cost shares for select services
such as knee and hip replacement,
sleep studies, and sinus surgery
Accidental Injury Benefit
out-ofnetwork
MENTAL HEALTH AND SUBSTANCE ABUSE
• Pediatric dental coverage
After meeting your deductible, you pay the
following amounts for covered services.
The deductible is waived for some covered
services. These are marked with ✓
in-network
EMERGENCY/URGENT CARE
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to
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out-ofnetwork
Inpatient hospital services and maternity care
lu
• A deductible that applies to the
out-of-pocket maximum
in-network
HOSPITAL SERVICES
Co
• Access to specialists and facilities via referral
from the medical home in order to receive
coverage at the in-network level
Connect 4000 Silver
OFFICE VISITS FOR MEDICAL SERVICES
home model provides a team of health professionals dedicated to your overall well-
Connect plans offer:
Connect 2000 Silver
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%
PRESCRIPTION DRUGS
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 ✓
$25 ✓
Covered ✓
$25 ✓
Covered ✓
Not Covered
Not Covered
Not Covered
Not Covered
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%
ADULT VISION SERVICES
Routine eye exams (limited to one
exam per calendar year)
Vision hardware (frames, lenses,
contact lenses) Limits apply
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
Preventive services (routine exams, cleanings,
x-rays, topical fluoride, and sealants)
13
Standard
Standard (continued)
Benefits 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.
Providence EPO Network: A network of nearly
1 million health care providers nationwide, both
in Providence facilities and in other locations.
Standard plans offer:
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
innetwork
out-ofnetwork
innetwork
out-ofnetwork
innetwork
out-ofnetwork
10%
50%
30%
50%
50%
50%
Emergency services
10%
10%
30%
30%
50%
50%
Urgent care services
$60 ✓
50%
$90 ✓
50%
$120
50%
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%
Inpatient and residential services
10%
50%
30%
50%
50%
50%
Outpatient provider visits
$20 ✓
50%
$35 ✓
50%
$60
50%
10%
50%
30%
50%
50%
50%
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
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
HOSPITAL SERVICES
Inpatient hospital services and
maternity care
• Copays starting as low as $20 and
deductibles as low as $1,300
EMERGENCY/URGENT CARE
• A deductible that applies to the
out-of-pocket maximum
• The freedom to choose any provider in
and out of the Providence EPO Network
OUTPATIENT DIAGNOSTIC SERVICES
• 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.
MENTAL HEALTH AND SUBSTANCE ABUSE
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory
surgery center or hospital-based facility
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 ✓
Annual Deductible Individual/Family
Annual Out-of-Pocket Maximum
Individual/Family
Chiropractic manipulation and
acupuncture
Providence Oregon
Standard Gold
Providence Oregon
Standard Silver
Providence Oregon
Standard Bronze
innetwork
out-ofnetwork
innetwork
out-ofnetwork
innetwork
out-ofnetwork
$1,300/
$2,600
$2,600/
$5,200
$2,500/
$5,000
$5,000/
$10,000
$5,000/
$10,000
$10,000/
$20,000
$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 ✓
Maternity prenatal care
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 ✓
Covered
in full ✓
Covered ✓
Covered
in full ✓
Covered ✓
Covered
in full ✓
Covered ✓
50%
Covered in
full ✓
50%
Vision hardware (frames, lenses,
contact lenses) Limits apply
Covered in
full ✓
50%
Covered in
full ✓
50%
ADULT VISION SERVICES
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
Routine eye exams (limited to
one exam per calendar year)
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Mammograms
Covered in
full ✓
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
Vision hardware (frames, lenses,
contact lenses) Limits apply
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Colorectal cancer screenings (age 50 and
over)
Covered in
full ✓
50%
Covered in
full ✓
50%
Covered in
full ✓
50%
Preventive services (routine
exams, cleanings, x-rays, topical
fluoride, and sealants)
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Personal Physician/Provider
$20 ✓
50%
$35 ✓
50%
$60
50%
Specialist
$40 ✓
50%
$70 ✓
50%
$100
50%
Basic services (includes restorative
fillings - silver and composite,
and space maintainers)
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Alternative care provider
(e.g.,naturopath, chiropractor,
acupuncturist)
$40 ✓
50%
$70 ✓
50%
$100
50%
Major services (includes oral surgery,
crowns, bridges, periodontics,
endodontics/root canals, dentures)
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
Not
Covered
50%
Covered in
full ✓
Covered in
full ✓
50%
Gynecological exams; Pap tests
Covered in
full ✓
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
OFFICE VISITS FOR MEDICAL SERVICES
14
PRESCRIPTION DRUGS
15
Essential
Essential (continued)
The Essential plan covers you in case of unforeseen major medical expenses.
After meeting your deductible, you pay the following
amounts for covered services. The deductible is waived for
some covered services. These are marked with ✓
This catastrophic plan is available only to individuals aged 29 years and younger.
The Essential plan offers:
• Affordable coverage with lower monthly premiums
Providence EPO Network: A network of nearly
1 million health care providers nationwide, both
in Providence facilities and in other locations.
Providence Essential
in-network
out-of-network
Covered in full
Covered in full
HOSPITAL SERVICES
Inpatient hospital services and maternity care
EMERGENCY/URGENT CARE
• Coverage for up to three personal physician/provider
office visits per calendar year before the deductible
is met
Emergency services
Covered in full
Covered in full
Urgent care services
Covered in full
Covered in full
• Prescription drug coverage
OUTPATIENT DIAGNOSTIC SERVICES
• The freedom to choose any provider, in and
out of the Providence EPO Network
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
Inpatient and residential services
Covered in full
Covered in full
Outpatient provider visits
Covered in full
Covered in full
Covered in full
Covered in full
Not Covered
Not Covered
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
Routine eye exams (limited to one exam per calendar year)
Covered in full ✓
Covered ✓
Covered in full ✓
Covered ✓
MENTAL HEALTH AND SUBSTANCE ABUSE
OTHER COVERED SERVICES
Outpatient surgery at an ambulatory surgery center or hospitalbased facility
Chiropractic manipulation and acupuncture
PRESCRIPTION DRUGS
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
PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19)
in-network
out-of-network
Vision hardware (frames, lenses, contact lenses) Limits apply
Annual Deductible Individual/Family
$6,600/$13,200
$13,200/$26,400
ADULT VISION SERVICES
Annual Out-of-Pocket Maximum Individual/Family
$6,600/$13,200
$13,200/$26,400
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
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
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
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
PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19)
OFFICE VISITS FOR MEDICAL SERVICES
Personal Physician/Provider
16
17
Compare our 2015 plans side-by-side
Plan name
Providence
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
Providence 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
Not covered
Not covered
Not covered
Not covered
Not covered
PPP office visit
$20 3
$35 3
$25 3
$25 3
$25 3
$25 3
$25 3
$25 3
50%
$60
50% first 3 visits 3
Specialist office visit
$40 3
$70 3
$50 3
$50 3
$50 3
$50 3
$50 3
$50 3
50%
$100
Covered in full
Not Covered
Not Covered
$25 3
$25 3
$25 3
$25 3
$25 3
$25 3
Not Covered
Not Covered
Not Covered
Prescription Drugs (generic)
$10 3
$15 3
$15 3
$15 3
$15 3
$15 3
$15 3
$15 3
50%
$20
Covered in full
Preferred brand name drugs
$30 3
$50 3
$60 3
$60 3
$60 3
$60 3
$60 3
$60 3
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 3
$90 3
$75 3
$75 3
$75 3
$75 3
$75 3
$75 3
50%
$120
Covered in full
Mental health - Outpatient visits
$20 3
$35 3
$25 3
$25 3
$25 3
$25 3
$25 3
$25 3
50%
$60
Covered in full
30% 3
30% 3
30% 3
30% 3
30% 3
30% 3
50%
50%
Covered in full
Not covered
Where to buy
Accidental Injury Benefit
Chiropractic manipulation
& Acupuncture
Outpatient diagnostic lab & x-ray
Adult vision exams
Pediatric vision (exams & hardware)
Pediatric Dental
The deductible is waived for all covered
services required to treat an accidental injury within 90 days of injury
10%
30%
Not covered
Not covered
$30 3
$30 3
$30 3
$30 3
$25 3
$25 3
$25 3
Not covered
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
Covered in full 3
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
*Connect plans are not available for
purchase in Yamhill county.
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
Wahkiakum
Cowlitz
Klickitat
bia
Clark
W
a
k shin
Hood
gt Multnomah River
oo
on
lam
Til
um
m
lu
Clatsop
l
Co
Co
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
Skamania
3 Deductible waived for these services
Lincoln
rm
an
She
Wasco
Wallowa
Morrow
Union
W
as
hi
ng
to
n
Gilliam
Marion
Jefferson
Benton
Polk
Umatilla
a
bi
Clackamas
Yamhill
Baker
Wheeler
Grant
Linn
Multnomah
Hood
River
Crook
18
Lane
Deschutes
Clackamas
Yamhill
Coos
Harney
Douglas
Polk
Curry
Josephine
Malheur
Jackson
Klamath
Lake
Marion
19
Glossary of Terms
Accidental injury
Marketplace
An injury that is due directly to an unintentional act,
independent of all other causes.
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.
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.
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.
• 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
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.
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
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
Exclusion
A service or supply not covered by the health plan.
Premium
Exclusion period
The monthly rate you pay for health plan coverage.
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.
Provider network
Certain covered services have a plan maximum for
coverage for a set period of time, usually a calendar year.
Several factors make up your monthly premium rate:
Participating 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.
Limitations
20
Individual and Family plan rates for 2015
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.
21
Individual and Family Plan Rates, Group A: Non-Tobacco User
Group A counties:
Clackamas, Multnomah, Washington, Yamhill*
Purchase 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.
*Connect plans are not available for purchase in Yamhill county.
Effective Jan. 1, 2015 – Dec. 31, 2015
Age
Age
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 ———————————————————
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
Age
22
Age
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 ———————————————————
23
Individual and Family Plan Rates, Group A: Tobacco User
Group A counties:
Clackamas, Multnomah, Washington, Yamhill*
Purchase 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.
*Connect plans are not available for purchase in Yamhill county.
Effective Jan. 1, 2015 – Dec. 31, 2015
Age
Age
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 ———————————————————
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
Age
24
Age
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
———————————————————————————————————————
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.
——————————————————— Not available to people age 30 and older ———————————————————
25
Individual and Family Plan Rates, Group B: Non-Tobacco User
Group B counties:
Purchase 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.
Benton, Douglas, Jackson, Josephine,
Lane, Linn, Marion, Polk
Effective Jan. 1, 2015 – Dec. 31, 2015
Age
Age
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 ———————————————————
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
Age
26
Age
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 ———————————————————
27
Individual and Family Plan Rates, Group B: Tobacco User
Group B counties:
Purchase 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.
Benton, Douglas, Jackson, Josephine,
Lane, Linn, Marion, Polk
Effective Jan. 1, 2015 – Dec. 31, 2015
Age
Age
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 ———————————————————
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
Age
28
Age
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
———————————————————————————————————————
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.
——————————————————— Not available to people age 30 and older ———————————————————
29
Individual and Family Plan Rates, Group C: Non-Tobacco User
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
Purchase 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
Age
Age
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 ———————————————————
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
Age
30
Age
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 ———————————————————
31
Individual and Family Plan Rates, Group C: Tobacco User
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
Purchase 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
Age
Age
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 ———————————————————
Age
Metal Level
32
Age
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
———————————————————————————————————————
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.
——————————————————— Not available to people age 30 and older ———————————————————
33
Decision-Making Guide
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.
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.
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.
Plan name
Plan name
Plan name
Pros
Pros
Pros
Cons
Cons
Cons
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-ofpocket 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.
Monthly
premium
Monthly
premium
Monthly
premium
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.
Subscriber
Subscriber
Subscriber
Notes:
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
________________________________________________________________________________
________________________________________________________________________________
34
35
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
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.
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