How do employer plans with first dollar coverage work?
How it works:
The first step is to identify which type of coverage you have. Open the member portal and navigate to your digital member id card. If your plan has “(0/)” preceding the deductible amount like the image below, your plan provides first dollar coverage for commonly used services.
In other words, you will not have to pay anything for the following services up to the Benefit Amount regardless of whether your deductible has been met:
- Provider office visits‡
- Primary care provider office visits‡
- Telehealth visits
- Specialist office visits
- Mental Health provider office visits
- All prescription drugs*
Additional services rendered at the time of the office visit are subject to any applicable deductibles.
*First dollar coverage applicable to covered outpatient prescription drugs.
‡Additional services rendered at the time of the office visit are subject to any applicable deductibles.
What is a “visit” or “office visit?”
An “office visit” is an appointment time with a provider to discuss new or existing problems. The questions and exam will focus on the problems discussed. An office visit can sometimes cover: a diagnosis, treatment plan, exam, coordination of healthcare, healthcare advice, and/or prescription of medication. An office visit can occur in the provider's own office or as part of an urgent care visit.
During an office visit, your provider may refer you for other services such as labs, imaging or other procedures. Only the office visit is covered before deductible, other services the provider recommends may be subject to deductible.
How do I know what services are covered?
First, check the “Estimate care” tab within the member portal. When searching for relevant care or prescriptions, you will find a “Deductible waived” flag, noted below the “Avg. cash price” and “Benefit Amount” sections. Example below:
For full coverage details, go to your "My coverage" page in your account, click on the three-line menu, and select “Full benefits.”
Another way to check if your service is covered is by looking at the CPT code (Current Procedural Terminology (CPT®)) for your visit. CPT codes are a uniform language for coding medical services and procedures. The following is a list of CPT codes for services in which the deductible will be waived in addition to preventive care and all prescription drugs*:
1. Office visits (with either a PCP/General Practice physician, a SCP, or Specialist e.g. Cardiologist visit or Immunologist visit etc., including in an urgent care setting):
- 99201-99205 for new patients
- 99211-99215 for established/returning patients
2. Telehealth visits
- 99421-3 or 99441-3 are the most commonly used codes
- 99201-99215 codes plus the -95 modifier (to indicate telehealth) are also sometimes used
3. Mental Health therapy services
- 90832, 90834, or 90837
This list is not comprehensive but is meant to be a helpful guideline. The deductible will apply to CPT codes on your itemized medical invoice that doesn’t fall under the six categories outlined. If you have questions about specific CPT codes or would like a list of applicable CPT codes, call Member Care.
*First dollar coverage applicable to covered outpatient prescription drugs.
What is an example of an office visit vs. additional services rendered?
If you visit a specialist (an Orthopedic surgeon for example) and the provider orders an MRI during the visit, only the cost of the office visit is covered up to the Benefit Amount, pre-deductible. The MRI is covered up to the Benefit Amount after any applicable deductibles have been met, otherwise, the Benefit Amount will be applied to your deductible.
As a member, you can compare provider prices for additional services rendered as you would any other care.
What if my first dollar service costs more or less than my plan’s Benefit Amount?
Services are covered up to the plan’s Benefit Amount. If a visit costs more than the Benefit Amount, you will be responsible for the amount above the Benefit Amount. If a visit costs less than the Benefit Amount, then you keep the savings.
How are first dollar services applied to the deductible?
For first dollar services without cost-sharing, no amount is applied to the deductible, regardless of the amount you paid above or below the Benefit Amount.
For example, if you have a mental health visit, you will not be charged for the visit up to the Benefit Amount. As such, the Benefit Amount for your visit will not be applied to your deductible.
Coverage and benefits subject to plan terms and conditions.
This plan is not HSA compatible.
