The first step in selecting a plan starts with understanding your medical usage, specifically anticipating what your needs will be in the coming year. Consider whether your coverage needs have changed because of the birth of a child or a change in marital status.  

Example A. You are in good health and only visit the doctor for annual check-ups and an occasional illness. You might be comfortable with a plan that has a lower monthly payment with a higher fees and deductibles when you require services.

Example B. You have a condition requiring frequent doctor visits, medications, and maybe even hospitalization. You might be more comfortable with a plan that has a higher monthly premium, but lower fees and deductibles when you require services.

Review the plans your employer is offering. Not all the Medical Trust plans are available in every region, and employers offer different options. Ask your group benefits administrator which plans are available to you.

If so, compare it to what your employer is offering to see which best meets your needs.

Review the summaries of benefits and coverages for
the plans you are considering to see costs for routine doctor visits, specialist care, and hospitalization, among other details. Some of the most important items to compare include the following:

The deductible is the amount that you must pay out-of-pocket before most benefits become available. The Medical Trust has plans that offer a range of deductibles for network providers. All plans have separate single and family deductibles, and all have deductibles that apply separately to network benefits and out-of-network benefits. Be sure to identify the deductible amounts that would apply to you in each of the plans.

Most of the plans offered by the Medical Trust have an embedded deductible.

• Once each member of your family has met the individual deductible, this Plan will begin to provide benefits for that individual. The individual deductible is also credited toward the family deductible. Once the family deductible has been met, all covered members of your family will receive benefits, whether or not they have met the individual deductible.

The Anthem and Cigna CDHP-15 provides a non-embedded deductible and out-of-pocket limit.

• If you have single coverage, then the Plan will begin to provide benefits once you have met the individual deductible. If you have spousal or family coverage, then the family deductible must be met before the Plan begins to pay for benefits for any covered family member, and the family out-of-pocket limit must be met before the Plan begins to pay 100% for any covered family member.

The out-of-pocket limit is the maximum out-of-pocket expense you will be responsible for during the plan year. Again, the Medical Trust’s plans have out-of-pocket amounts for single and family plans, and for network and out-of-network benefits.

Coinsurance is the percentage you pay for medical services, for example 10% of hospitalization costs. You pay coinsurance until you meet your plan’s out-of-pocket limit.

Copays are fixed amounts that members pay, for example, $30 for an office visit. Copays apply toward out-of-pocket limits, so when you reach your out-of-pocket limit for the calendar year, you will not be charged copays.

The Medical Trust’s consumer-directed health plans (CDHPs) do not have copays. Members pay all medical expenses out-of-pocket, often funded by a health savings account (HSA), up to the deductible. After reaching the deductible, members pay a coinsurance amount for services. All coinsurance payments count toward the out-of-pocket limit, after which all covered medical services are provided without charge for the remainder of the plan year.

Office visits are perhaps the most common use of medical benefits. Many of the Medical Trust’s plans require a copay for office visits, with different amounts for primary care physicians, specialists, and urgent care centers. Some plans have a coinsurance payment rather than a copay for office visits.

Hospitalization, including outpatient surgery, is a significant medical expense. Most of the Medical Trust’s plans have only a coinsurance payment.

You’ll want to ensure that your preferred doctors and local facilities are in your plan’s network. To do so, you can go online to the plan’s website and use their “locate a doctor/provider” service or call the plan for the most up-to-date information. See Contact Information. 

Next, consider the process for accessing specialists, and whether this is important for you. Do you need a referral from your primary care provider before you can see a specialist (required by the Kaiser plans) or can you self-refer (typical for PPO plans)?

Another consideration many people find important is whether they can access out-of-network services and still be covered. The Medical Trust offers some plans that provide network-only benefits. These EPOs have no out-of-network coverage, except in an emergency. We also offer plans that provide out-of-network benefits, although at a lesser reimbursement than network benefits. If you want to retain the choice of coverage for services from out-of-network providers, select a PPO or CDHP.¹

The following is a list of the Medical Trust benefit plans offering only network coverage. (These plans may or may not be offered by your employer.)

• Kaiser Permanente plans (all)

The Medical Trust offers two prescription drug options – Standard Rx and Premium Rx.

The Standard Rx option is coinsurance-based (versus copay-based) with maximum amounts to protect members from excessive costs and minimums to drive plan savings. The Premium Rx option is based on copays. Employer groups decide which prescription drug option they will offer to their employees.

The CDHPs and Kaiser plans offer pharmacy benefits that differ in certain aspects from the Standard Rx and Premium Rx prescription drug options. Please see plan details for more information. (Please note: CDHPs are not offered by all employers.)

The Medical Trust’s behavioral health benefits are totally compliant with federal regulations requiring parity for physical health benefits. Members should review the copays and/or coinsurance amounts applicable to office visits and in-patient care for this benefit.

All the Medical Trust plans offer services that do not require the deductible to be met. These include:

• Vision. Our plans have no copay for an annual eye exam with a network provider. In addition, the vision benefit, provided through EyeMed, has a small copay for lenses and contact lens fit, as well as a generous annual allowance for frames or contacts, which are not applied to the medical deductible or out-of-pocket maximum. 
• Employee Assistance Program. The Medical Trust’s Employee Assistance Program (EAP), managed through Cigna Behavioral Health, is part of all our plans. Licensed clinicians can help with almost any issue, including stress, elder care, legal/financial issues, substance use disorder, and emotional and physical health. Services are free, confidential, and available to all members of your household, even non-covered family members. The plans cover telephone consultations and up to 10 in-person visits per issue with no copay and no deductible.
• Health Advocate. This service is available with all our plans and provides free hands-on assistance for all types of medical and administrative issues. Health Advocate can help members, their spouses, dependents, parents, and parents-in-law resolve claims issues, find doctors or hospitals, handle elder care issues, understand treatment options, find community resources, and schedule appointments with hard-to-reach specialists.
• Travel Assistance. UnitedHealthcare Global Assistance provides travel assistance services for Medical Trust plan members traveling at least 100 miles from their primary residence.

The Medical Trust’s plans offer many other benefits and services when medically necessary, such as:

• Acupuncture
• Allergy testing
• Applied behavior analysis therapy for autism spectrum disorder
• Bariatric surgery
• Chiropractic care
• Hearing aid devices
• Infertility diagnosis and treatments
• Maternity services
• Smoking cessation

Members should review the cost and coverage of the benefits and services that are important in their situations when comparing the Medical Trust’s plans.