BASIC INSURANCE Q&A’S
Health insurance is a list of medical benefits that an insurance company agrees to cover when you meet certain requirements. You pay a premium each week for this coverage; it is automatically deducted from your paycheck with The Ōnin Group. When you use the insurance, we will pay part or all of the costs based on your specific insurance contract, called a policy.
Health insurance helps to protect you from the high costs of medical procedures. In the past, US citizens were required to have basic coverage either through their employer, a private insurer or the government. If you did not have health insurance, you would be fined each year. In 2019, that has changed in most states around the country, and you will no longer be penalized. This means you won’t have to pay extra money for not having insurance. Insurance policies include some basic preventative benefits to help keep you healthy, and cover other conditions as well. The amount of coverage you have depends on the policy you pick.
A premium is the amount of money that is deducted from your paycheck each week to pay for your insurance plan. It is the fee you pay for the service, like your cable bill or Netflix. Basically, money is taken out of your check and we pay it to the insurance company for you.
A copay is what you pay when you go to the doctor’s office. The amount of this copay will vary based on the type of plan you choose. You will pay this each time you visit the doctor.
Coinsurance is the percentage of the bill you will have to pay when you go to the doctor. You will pay part and your insurance company will pay the rest. You will pay the coinsurance amount at the time of service or you will pay it when you receive it in the mail as a bill.
A deductible is the total amount you will have to pay for medical services before your insurance starts to help you pay for your medical expenses. Your deductible is based on the type of plan you choose. It is important that you pick a plan that has a deductible you can afford. Our Teammate/Medical MEC Plan is a no deductible plan, so the insurance company will immediately begin to help pay for your services.
A no deductible plan means you do not have to pay any money toward your medical bills before your insurance begins to help you pay.
- Deductible Plan: Jane’s deductible insurance plan requires her to spend $2,000 on medical services before insurance will help her pay.
- No Deductible Plan: Joe’s no deductible plan immediately helps him pay to visit a specialist even though Joe has not spent any money (except his premium) for health insurance so far this year.
Our Teammate/Medical MEC Plan can be used in the PHCS network. The Bronze Plan is used in the CIGNA network. To find the doctors and hospitals available in your area, call the Advocate line at 833-751-1096.
- If you choose the Teammate/Medical MEC Plan, it is best to add up the copays for each service you expect to use. You will only pay your copay costs instead of a high deductible amount first. This means your insurance will automatically begin helping to pay for your covered expenses. This is great, because many plans require you to pay thousands of dollars before insurance will help you pay for your medical expenses. If you only plan to work with Ōnin for a limited amount of time, this insurance plan is a great option, because you can immediately receive financial help from the insurance company for your medical expenses. That said, for the remaining estimation, you do not have a maximum out-of-pocket amount with this plan, so there is no limit to the amount of money you can spend on healthcare.
- If you choose the Bronze Plan, multiply the cost of your premiums by 52 weeks, then add your out-of-pocket maximum. This is the highest total amount you would have to pay in a year for your health insurance. That will cover your premiums, copays, coinsurance and deductibles. You may not reach your maximum in the year, but that is the MOST you would have to pay. However, often people do not meet their deductible amount or maximum out-of-pocket within a year, which is important to remember when selecting plan. If you need more information about this plan’s costs, call the Advocate line 833-751-1096.
Yes, you have the ability to opt-out of the insurance. You must do this yourself; Ōnin’s staff cannot do this for you.
You will need to call the Enrollment Assistance line at 833-236-7463 or visit worxenroll.com/oningroup to opt-out of or choose a different insurance plan. If you do not opt-out or choose a different plan, you will be automatically enrolled in the Teammate/Medical MEC individual plan.
For the Teammate/Medical MEC Plan, you do not have to pay any deductible. This is helpful for you because it means your insurance will automatically begin to help you pay for your healthcare bills that are covered by the plan. If think you may only work with Ōnin for a short period of time, this is a great option because you can immediately receive amazing prices on health services – including $5 prescriptions, free online or telephone unlimited visits with a doctor through our teledoctor program, and two $5 in-person visits with your doctor.
For the Bronze Plan, you must meet a deductible ($3,000 for a single person plan or $9,000 for a family plan) before insurance begins to help you pay your medical bills. This is a lot of money to spend before insurance begins to pay for your services, especially if you think you may only work with Ōnin for a short period of time, which is why we custom-built the Teammate/Medical MEC Plan.
Deductibles works like this: When you go to the doctor, you will be charged for the service you received in addition to your copay. Although some preventative services are free, most of the time you will get a bill for your visit. Once you’ve met your deductible, meaning you’ve spent the deductible amount ($3,000 for a single person and $9,000 for a family plan in the Bronze Plan) on your medical costs, the insurance company starts to pay part of the bills. You will still pay your copay, plus your part of the bill, which is called coinsurance.
Your maximum out-of-pocket refers to the total amount of money you have to pay for services covered by your insurance plan in a year. There are a few exceptions though. The maximum out-of-pocket does not include your premiums, balance-billed charges, healthcare costs not covered by the plan, or penalties for not pre-authorizing your service.
For instance, if your maximum out-of-pocket is $6,500 for a single person plan or $13,200 for a family plan, like in the Bronze Plan, you won’t have to pay for any more money on in-network services for the rest of the year, but you will still have your premiums deducted from your paycheck.
We offer plans for you, you and your spouse, you and your children, or you and your family (spouse and children). Who is covered by your policy will depend on the type of plan you pick. If you choose an individual plan, you will be the only person covered by the insurance and additional benefits, like the Vision Plan, MYidealDOCTOR and the Employee Assistance Plan. However, if you choose other coverage, this can include your legal spouse, and children for which you are legally responsible who are under the age of 26, who live with you or who attend school.
You will start paying your premium (the amount of money taken out of your paycheck each week) the first pay period after you have reached your 30 days of working with Ōnin. At this point, you can begin using your insurance policy and you will receive an insurance card in the mail. If you do not sign up for the insurance plan of your choice or opt-out, you will be automatically enrolled in the Teammate/Medical MEC individual plan.
There are three ways to change your coverage once you have signed up for insurance with Ōnin:
- Open Enrollment – every year around November, we allow our Teammates who have worked 30 days, or more, to change their health insurance coverage. You will be notified through the Teammates App, mail and with signs in our offices. Be sure you make changes during this time.
- A Life Changing Event – there are a few specific situations that happen in life where the government allows us to make changes to your insurance policy outside of open enrollment. These events include: marriage, birth or adoption of a child, death, divorce, gaining/losing coverage through a spouse’s employment or turning 26-years-old. If you experience one of these events call the Enrollment Assistance line at 833-236-7463.
- Ending Employment with Ōnin – if you are out of an assignment for more than 13 weeks, your insurance coverage will be cancelled. We will be able to start a new policy for you on your first pay period 30 days after you begin working with Ōnin again.
Previously, under the Affordable Care Act, all US citizens were required to have qualifying healthcare coverage. If you did not have coverage, you could be penalized with fines. Our insurance plans are designed to meet these requirements. In 2019, the federal individual penalty will no longer be fined when you file taxes in 2020. In other words, in 2019, you will not be required by federal the government to have health insurance. Some states may still have their own penalties, so check what your state requires.
The prescription coverage will vary based on the type of medicine you take and the plan you choose. Under the Teammate/Medical MEC Plan, generic prescriptions are $5.00. Under the Bronze Plan, generic prescriptions are $15.00. All prices are based on a 30-day prescription. For specific questions about other medications, please call the Advocate line at 833-751-1096.
- If you sign up for benefits for the first time with Ōnin: Your effective date is the pay period following 30 days after you started working for Ōnin.
- If you had medical benefits with Ōnin through the end of 2018: Your new medical plan starts at the beginning of the year, in January 2019.
Once you have insurance through Ōnin, we are unable to cancel your policy unless you have a qualifying life event (like marriage or birth of a new child), your assignment is ended for 13 weeks or you stop working with Ōnin. If you quit working at Ōnin, you are fired from Ōnin or you are hired permanently by a company, your insurance policy will be cancelled.
No. As an Ōnin Teammate, you are required to enroll in a medical insurance plan to enroll in a dental insurance plan with us.
No. In order to get Ōnin vision insurance, you must be signed up for Ōnin’s Teammate/Medical MEC Plan or Ōnin’s Bronze Plan.
You must be employed with Ōnin for 30 days from your start date. When you have reached the pay period following 30 days of hire, you will receive an insurance card in the mail five to seven business days later. If you do not receive this card, call the Advocate line (833-751-1096) for help.
The Teammate/Medical MEC was custom-built for our Teammates’ needs. The plan offers more comprehensive coverage for our Teammates and their families. It provides copays starting at $5.00, plus there is no deductible with this plan, meaning your insurance will immediately help you pay for your doctor’s visits. It also includes our teledoctor service, EAP benefits and the Vision Plan at no extra cost. If you think your medical costs will be less than $6,500 for yourself or $13,200 for your family, this plan may be a good option.
The Bronze Plan has a high deductible. In other words, you will have to pay $3,000 with an individual plan or $9,000 with a family plan before your insurance starts to help pay your medical bills. It offers basic coverage and preventative health screenings. It includes our teledoctor service, EAP benefits and Vision Plan at no extra cost. This plan provides a maximum-out-of-pocket of $6,500 for the individual plan and $13,200 for the family plan. If you expect your medical expenses to cost more than these amounts during your time at Ōnin, this plan may be a good option.
Enrolling your spouse or dependents into your insurance is a personal decision. We have custom-built our plans to be affordable and usable for our Teammates and their families. However, we encourage you to compare Ōnin’s insurance benefits with your husband or wife’s plan to see which offer is best for you and your family. If your spouse has a health insurance plan which works better for your needs, you can choose that plan and call the Enrollment Assistance line at 833-236-7463 to opt-out of automatic enrollment for the Teammate/Medical MEC Plan.
We have representatives available to help you with all of your questions. Call the Enrollment Assistance line at 833-236-7463 if you are not currently enrolled in Ōnin benefits and have questions. If you are currently enrolled in an Ōnin benefits plan, call the the Advocate line at 833-751-1096. It is important to us that you understand how to use your insurance and make it work best for you.
It can be frustrating and scary when medical bills are coming in and not paid as you thought they would be. There can be many reasons for this, from coding errors to non-qualified services. Please call the Advocate line at 833-751-1096 and a representative will help you with your concerns.
You must call us at the Enrollment Assistance line at 833-236-7463 or visit worxenroll.com/oningroup before you have worked with Ōnin for 30 days from your start date to let us know you do not want the health insurance. If you do not call this number or visit the site, you will be enrolled in the Teammate/Medical MEC single plan and will not be able to cancel or change it until open enrollment in November of next year unless you have a major life event.
If you want the Teammate/Medical MEC Plan for a single person, you don’t have to take any action. You will automatically be enrolled after 30 days. If you want to add other family members, add dental insurance, pick the Bronze Plan, or opt-out of the plan, you will need to call us the Enrollment Assistance line at 833-236-7463 or visit worxenroll.com/oningroup to make those changes before 30 days after you are hired. Unfortunately, the branch cannot do this for you, so you must call the Enrollment Assistance line or visit the website to make your selection.
Your health is important to us, and we know medical benefits should not be expensive and should be easy for you to use on your busy schedule. That’s why, in 2019, we are offering new, custom-built benefits which are affordable and usable. By surveying Teammates and Ōninites in the field, speaking with experts and after a lot of thought, we have custom built the Teammate/Medical MEC plan, which has no deductible, low copays, as well as free teledoctor and counseling services. Your body, mind, mouth and eyes are taken care of. We know it’s hard to see a doctor if you can’t afford one. We hope these affordable and easy-to-use plans help you and your family to stay healthy and happy.
Choosing a Plan
No matter which plan you choose, when you have medical insurance through Ōnin Staffing, you also receive a Vision Plan, teledoctor services and an Employee Assistance Plan (EAP) at no extra cost!
Starting in 2019, you are not required to have health insurance in most states any longer. However, if you opt-out of coverage, you will not have access to the Vision Plan, telemedicine services or EAP. To opt-out, you must call the Enrollment Assistance line at 833-236-7463 or visit worxenroll.com/oningroup.
If you do not choose a plan or opt-out of insurance within 30 days of being hired, you will automatically be enrolled in the Teammate/Medical MEC Plan. You will need to call the Enrollment Assistance line or visit worxenroll.com/oningroup before the end of your 30 days if you want the Bronze Plan instead, want to add dependents or opt-out of the insurance.
Here’s a snapshot of our major medical plans:
The Teammate/Medical MEC Plan is a no deductible plan. This means you will have medical insurance you can use the first pay period following 30 days from your start date with Ōnin. This plan offers lower copays, $5 generic prescriptions, two $5 in-person primary care visits, and is truly usable insurance. There is no out-of-pocket maximum, which means you will pay your copay each time you receive medical care for all covered visits and procedures.
The Bronze Plan meets the Affordable Care Act requirements. This plan is a high-deductible plan where you will pay more out-of-pocket when you use a doctor for more than preventative care. Copays to see a doctor or specialist are higher than our Teammate/Medical MEC Plan. Also, you must meet your deductible ($3,000/$9,000) before the insurance begins to help cover some of the medical costs. This plan does offer a maximum out-of-pocket of $6,500 for the individual plan and $13,200 for the family plan, which means you will not spend more than this amount in a year, although you will still have to pay your premiums.
It is important to remember, you can use our teledoctor services for free, from anywhere, to avoid traditional, time-consuming office visits and fees by selecting one of our insurance plans.
Joe is a single guy who works a late second shift, but he doesn’t let this stop him from keeping up with his health needs. Joe is trying to deal with his recent divorce and is having some financial problems. Since he works later than most doctor’s offices are open, having healthcare options that work with his schedule is important.
Lisa is a woman on the move with her busy family life and a full-time job. Being married with three children means great medical options are a must to keep her family healthy, happy and cared for. With so many responsibilities, Lisa needs on-the-go options for her family’s physical and mental health needs.
What Ōnin Provides
24-hour access to U.S. board-certified physicians, seven days a week, 365 days a year.
A doctor will consult with you about your condition, diagnose your issue and can prescribe medication for you. They can even send your prescription to your pharmacy of choice.
You can speak to a doctor by phone or video chat. You can use a landline phone, a mobile device or computer. There is an app, a website and a phone number to use (below).
You can set a time for the doctor to call back or receive a call within about 30 minutes.
The teledoctor service is great to use when you are considering an urgent care or ER visit for a non-emergency medical issue after hours; or if you don’t want to sit in a waiting room with other sick patients; or if you don’t want to wait to see your family doctor.
You and any covered family members older than 2 years old can use the service as a part of one of our medical plans.
Treated common conditions like the following:
Urinary tract infections
And much more
Call 855-879-4332 and enter MYIDR1489
Online at myidealdoctor.com
On the MYidealDOCTOR App
Download through Google Play or the App Store
Joe is a single guy who works second shift. He gets off work on Friday at 11:00 PM and feels feverish with a nasty cough. His doctor won’t be in the office until Tuesday, due to the holiday weekend. He doesn’t want to sit at the ER all night.
Joe uses his MYidealDoctor app to request a doctor consultation. He then drives home. Fifteen minutes later, the doctor calls him back on his smartphone using the app.
The doctor asks Joe about his symptoms and has Joe take his own temperature. The doctor examines Joe’s mouth and throat through the camera on Joe’s phone using the app. The doctor concludes Joe most likely has the flu.
The doctor sends a prescription to a nearby 24-hour pharmacy. Joe drives to pick up the medication. On Monday, Joe is better and back at work.
Joe does not receive a bill, since teledoctor services are free. His only cost was the price of the prescription.
Lisa picks up her daughter at school on Wednesday after receiving a call from the nurse. Her daughter’s eye is itchy and watery.
Before heading home, Lisa calls the MYidealDoctor phone line to set up a callback. When she arrives home, she and her daughter talk to the doctor on the laptop.
The doctor looks at the little girl’s eye and sees that there is some mucus and drainage. The doctor determines it is pink-eye.
The doctor sends a prescription to Lisa’s neighborhood pharmacy. Lisa picks up the eye drops that afternoon.
By Friday, Lisa’s daughter is back at school and her condition is all cleared up.
Lisa only paid for the eye drops at the pharmacy because the teledoctor service is free!
Teammate / Medical MEC Plan
This plan offers Teammates radically affordable, radically easy to use benefits. This plan was created just for our Teammates and their unique job situation. Our Teammates are part of the Ōnin team, and they deserve an incredible benefits plan.
|TEAMMATE / MEDICAL MEC PLAN SUMMARY|
|Prescription Drugs (retail, 30-day supply):||$5 copay on generic|
|Primary Care Visits:||$5 copay first 2 visits, $25 copay visits 3 & 4|
|Specialist Visits:||$50 copay up to 4 visits per year|
|Urgent Care:||$60 copay up to 4 visits per year|
|Preventative Services:||Covered 100%|
|Teledoctor:||$0 consultation fee, 24/7/365|
|INPATIENT HOSPITAL BENEFITS||FIXED DOLLAR REIMBURSEMENT|
|Hospital Room & Board Benefits:|
|Daily Benefit for the Treatment of Mental & Nervous Conditions||$100 per day, up to 25 days|
|Daily Benefit for the Treatment of Alcohol & Substance Abuse||$100 per day, up to 25 days|
|Daily Benefit for the Treatment of All Other Covered Conditions||$200 per day, up to 90 days|
|Hospital Admission Benefit For Specified Conditions:|
|Daily Benefit for Cancer (Malignant Neoplasm)||$2,000 per day, up to 1 day|
|Daily Benefit for Heart Attack (Myocardial Infarction) OR||$1,500 per day, up to 1 day|
|Daily Benefit for Heart Disease||$1,000 per day, up to 1 day|
|Daily Benefit for Accidental Injury||$1,000 per day, up to 1 day|
|Daily Benefit for Stroke (Cerebrovascular Accident - CVA)||$1,000 per day, up to 1 day|
|Daily Benefit for Childbirth||$1,000 per day, up to 1 day|
|Maximum Surgery Benefit Per Procedure||$500 per day|
|Maximum Anesthesia Benefit||$100 per day|
|OUTPATIENT BENEFITS||FIXED DOLLAR REIMBURSEMENT|
|Doctor Visit Benefits:|
|Daily Benefit for a New Patient Office Visit||$75 per day, up to 1 day|
|Daily Benefit for an Established Patient Office Visit||$60 per day, up to 3 days|
|Daily Benefit for a Consultation Office Visit||$75 per day, up to 1 day|
|Daily Benefit for an Emergency Room Doctor Visit||$50 per day, up to 1 day|
|Daily Benefit for a Magnetic Resonance Imaging (MRI)||$100 per day, up to 1 day|
|Daily Benefit for a Computerized Tomography (CT) Scan||$50 per day, up to 1 day|
|Daily Benefit for all other Radiology Services||$40 per day, up to 3 days|
|Daily Benefit for all Pathology Services||$40 per day, up to 3 days|
|Urgent Care Benefits:|
|Daily Benefit for an Urgent Care Facility Visit||$50 per day, up to 1 day|
|Emergency Room Visit Benefits:|
|Daily Benefit for the treatment of an Accidental Injury||$500 per day, up to 2 days|
|Daily Benefit for the treatment of a Sickness||$50 per day, up to 3 days|
|Maximum Surgery Benefit Per Procedure||$500 per day|
|Maximum Anesthesia Benefit||$100 per day|
More Plan Details
Your first two visits are a $5.00 copay.
If you see a doctor a third or fourth time during the year, your copay will be $25.00 for those visits.
If you see a doctor more during the year, starting on visit five, you will pay the doctor’s office visit fee in full.
You can see a specialist as needed up to four times a year for a $50.00 copay.
Additional visits, starting with visit five, will be billed at the full rate the specialist charges to you.
You may visit an urgent care up to four times in a year for a $60.00 copay.
Additional visits, starting with visit five, will be billed at the full rate by the urgent care to you.
No copay, no fees, no waiting.
Use as an alternative to a traditional office visit.
24/7/365 access to licensed physician.
Contact by phone, computer or app.
Diagnosis and treatment for common conditions.
100% covered for these preventative services.
Generic prescriptions are a $5.00 copay.
Joe is a single man who works second shift. He gets sick at work. He leaves early and goes urgent care.
He sees a doctor and is prescribed an antibiotic. He pays his $60.00 copay before leaving the urgent care office.
He stops by the 24-hour pharmacy to get his prescription nearby. He pays $5.00 for his generic antibiotic.
Joe goes home and returns to work a few days later feeling better.
Lisa is a mother of three children. Her son, Thomas, has been coughing and sneezing for a few days. He wakes up with a 101 degree fever.
Lisa calls her family doctor and gets an appointment for Thomas for the following day.
Lisa and Thomas visit the doctor. Thomas has a common cold, and is told to take acetaminophen for the fever, drink lots of fluids and get plenty of rest.
Lisa pays $5.00 for her copay before leaving the office.
After a few days of following the doctor’s orders, Thomas is better and back at school.
At Ōnin, you have insurance options! The Bronze Plan is a high-deductible plan, unlike the Teammate/Medical MEC plan, which is a no deductible plan. This means you must first meet your deductible ($3,000/$9,000) before the insurance begins to help cover some of the medical costs. This plan offers a maximum out-of-pocket of $6,500 for the individual plan and $13,200 for the family plan, which means you will not spend more than this amount in a year, although you will still have to pay your premiums.
|Annual Calendar Year Deductible||In Network||Out of Network|
|Individual | Family||$3,000 | $9,000||$5,000 | $10,000|
|Maximum Calendar Year Out-of-Pocket|
|Individual | Family||$6,500 | $13,200||Unlimited|
|Primary Care Physician (PCP) | Specialist||$40 copay||Deductible + 40%|
|Specialist Visit||$80 copay||Deductible + 40%|
|Preventive Care Exam | Well Baby||Covered 100%||Deductible + 40%|
|Diagnostic Test Lab & Path X-ray & Imaging Other Diagnostic Examination||Deductible + 20%||Deductible + 40%|
|Imaging (CT/PET scans, MRIs) Outpatient Radiology Center Outpatient Hospital||Deductible + 20%||Deductible + 40%|
|Inpatient||Deductible + 20%||Deductible + 40%|
|Outpatient Surgery (Outpatient Hospital)||Deductible + 20%||Deductible + 40%|
|Emergency Room||Deductible + 20%||Deductible + 20%|
|Urgent Care||Deductible + 20%||Deductible + 40%|
|Retail (30 day supply)||Mail Order (90 day supply)|
|Preferred Brand||30% min $35||30% min $70|
|Non-Preferred Brand||40% min $70||40% min $150|
More Plan Details
Meets ACA requirements
Preventative, basic exams are covered at 100%
High deductible plan – $3,000/$9,000
Services are provided by the CIGNA network
You will be able to see your family doctor for a $40.00 copay each visit.
You will be able to see a specialist for a $80.00 copay.
For other medical services, you must meet your deductible ($3,000/$9,000) before insurance will pay. After you meet your deductible, you will pay 20% of the bill.
You can use urgent care for an $80.00 copay.
Generic prescriptions are $15.00.
Mental Health Employee Assistance Program (EAP)
We don’t just care about your physical health. Your mental health is just as important to us. If you need someone to talk to about a recent loss, depression, anxiety, debt or other issues for yourself or your covered family members, you can speak with a mental health counselor – for FREE.
More Plan Details
Counselors available 24 hours a day, 365 days a year by phone at 800-531-0200.
No copay or out-of-pocket cost…it is FREE.
Personal counseling services for mental health needs.
Professional counselors who possess either a master’s degree or Ph.D. with more than five years experience.
English, Spanish and French speaking therapists available.
Other languages available through interpretation services for counseling.
Available to all covered dependents.
Referrals available for in-person services (fees may apply at office).
Tools to help you be your best.
Joe is a single, recently divorced man working second shift. He doesn’t get a lot of time to socialize because most of his friends work days. He has been feeling tired lately and has no interest in trying to meet new people. His best friend thinks Joe may be depressed.
Joe calls and speaks with a counselor about his recent feelings, his anger at his ex-wife, the bills he can’t seem to keep paid, and that he doesn’t even try to meet new people.
The counselor talks to Joe about his finances and sends him some useful information by email. They discuss his anger with his ex-wife and ways to deal with her respectfully. They also talk about Joe’s mental state and possible depression.
The counselor and Joe agree to speak regularly and Joe keeps in contact with the counselor on bad days.
Joe is getting out with new and old friends, paying off debt and has a better life all around. And he pays nothing for these services.
Lisa is a mother of three children, and her son, Michael is always in trouble at school. Michael is angry and fights a lot with others in class and at home. Lisa is at her wit’s end.
Lisa calls the EAP line after Michael gets suspended from school for three days.
The EAP counselor talks to Lisa and Michael together and then invites the family to participate on the next call.
On the next phone call, Lisa, her husband, and three children talk to the counselor together by speakerphone. Overtime, Michael is doing better at school and the family has worked through some issues they didn’t realize were affecting them all.
Lisa still calls the EAP line from time to time. Sometimes she speaks to a counselor alone or she and the family talk to a counselor via speakerphone. Michael even talks to a counselor when he has had a rough week.
Lisa and her family pay nothing for these services.
If you and your family need dental insurance, Ōnin has you covered. This optional dental plan is not required and is not included with your medical plan. However, you can add it to your benefits when you enroll for a medical plan. There is an additional premium which will be withheld from your weekly paycheck if you add the Dental Plan.
|Annual Deductible - (Individual/Family)||$50/$150|
|Calendar Year Maximum Benefit||$1,000|
|Network||PDP Plus Network|
|In Network/Out of Network Coverage|
|DIAGNOSTIC AND PREVENTIVE SERVICES|
|Exams, Cleanings, Fluoride Treatments, X-rays||Covered 100%|
|Fillings, Simple Extractions, Basic Oral Surgery||Covered 50%|
|Periodontics, Endodontic (Root Canal), Crowns, Inalys, Onlays, Bridges, Dentures||Covered 0%|
More Plan Details
WITH NO COPAY
Exams once every six months.
Cleanings once every six months.
Bitewing X-Rays once every 12 months.
Fluoride one time in 12 months for children under 14.
AFTER YOUR COPAY
50% payment of these covered basic services after your copay of either $50 for an individual or $150 for a family.
Sealants for children under 16 on each molar every 60 months.
Space maintainers once per lifetime for children under 14.
Full mouth x-rays once in 60 months.
Amalgam fillings once replacement per surface every 24 months.
Periodontal maintenance twice per year including cleanings.
Scaling and root planing once every 24 months.
Other services at this rate are:
Emergency palliative treatment
Resin composite fillings
Oral surgery on simple extractions
You will pay 100% of the cost of these services, as they are not covered by this plan.
Consultations twice in one year
Root canal once per tooth per lifetime
Periodontal surgery once in any 36 month period
Prefabricated crowns every 10 years per tooth
Crown build ups or post core every 10 years per tooth
Repairs once per year
Recementations once per year
Dentures once every 10 years
Rebases or relines for dentures once every 36 months
Denture adjustments once a year
Fixed bridges once every 10 years
Inlays, onlays or crowns every 10 years per tooth
Implant services every 10 years per tooth position
Implant repairs once a year per tooth
Implant supported prosthetic every 10 years per tooth
Tissue conditioning once every 36 months
Occlusal adjustments once a year
Other services include:
Apexification and recalcification
Periodontal surgery for soft and connective tissue grafts
Surgical oral extractions
Other oral surgery
Joe is a single guy who likes to check on his oral health every year. He calls the dentist for his normal appointment, and he:
Has an examination and routine cleaning
Joe pays nothing to see the dentist this year
Lisa’s son needs to have cavities fixed. She calls the dentist and:
Her son has an exam and routine cleaning
Receives amalgam fillings on two teeth
Lisa is billed for 50% of the cost of the fillings after her $150 family deductible.
So, the two fillings were $69.00 each, or $138.00 total. The exam and cleaning were not billed to Lisa, as they are preventative services. Lisa pays her $138.00 which goes toward her deductible of $150.00. She still has $12.00 in services yet to be rendered before she meets her deductible. Preventative services are still without charge.
|Waiting Period/Coverage Election Date||1st Pay Period Following 30 Days of Employment|
|Basic Information||In Network|
|Eye Exam||100% after $10 copay|
|Contacts: Elective||Up to $100 Allowance|
|Eyeglass Lenses: Single, Bifocal, Trifocal||100% after $25 copay|
|Standard Frame||*Up to $100 Allowance|
|Frequency of Services||In Network|
|Comprehensive Eye Examination||12 Months|
|Laser Vision Correction||Discounts range from 10% to 50%|
|Name of Network||Superior National Network|
|Plan Provisions||*Frames: Up to 20% off amount over allowance|
More Plan Details
One eye exam each year.
You receive $100 for contacts
You can choose single, bifocal or trifocal lenses for a $25 copay.
You receive $100 for standard frames.
If your frames cost more than $100, you can save up to 20% on the remaining amount.
Joe is a single man who wears glasses. He breaks his old ones, so he goes to the eye doctor, where he:
- Pays $10 for his exam
- Pays $25 for his bifocal lenses
- Picks a $250 pair of frames
- He saves 15% on his remaining $150 balance
- Joe’s total amount he has to pay is $162.50
Lisa’s daughter wears contacts, and needs a new set. So, Lisa has family medical insurance and takes her daughter to the eye doctor, where she:
- Pays $10 for the exam
- Orders $175 in contact lenses
- Her total amount she has to pay is $85
Affordable Care Act - this federal law requires employers to provide healthcare insurance to their workers which meets minimum standards. Starting in 2019, employees are no longer required to have insurance by law, but employers must still offer it. Some states do require all citizens have healthcare insurance; as of late 2018, the following states were considering keeping the requirement for individuals to have health insurance or pay a penalty: Washington, California, Hawaii, Minnesota, Vermont, Massachusetts, Rhode Island, Connecticut, New Jersey, Maryland and the District of Columbia. If you live in one of these states, it will be important for you to check your state requirements before deciding to opt-out of insurance.
Antibiotic - a type of medicine which treats bacterial infections.
Balance Billing - this is the difference between the medical provider’s charge and the allowed covered amount. For example, if the doctor charges $100, but the allowed amount is $70, you will receive a bill for the remaining $30. You will need to pay this to the medical provider.
Brand Prescriptions - these are drugs which have a labelled name, for example, amoxicillin is an antibiotic which is available generically as amoxicillin. It’s brand names are Amoxil, Moxatag or Larotid. You may pay more for the brand name drug. You can choose between generic or brand name in many cases. However, some branded drugs do not have generic counterparts, and are not available at a lower prices.
Claim - a bill for your medical services received.
Coinsurance - the part of the bill you pay after you meet your deductible.
Consultation - the exam the doctor does to find out what the problem is or from what illness you are suffering.
Copay - what you pay when you walk in the doctor’s office (which can vary depending on what services you are using and what kind of doctor you are seeing).
Covered Services - this is the medical treatment you receive for which your insurance company pays part or all of the bill.
Deductible - how much you will pay before any medical bills are paid by your insurance.
Dependents - these are the other people in your immediate family you want to add to your policy. This can include your legal children, stepchildren, adopted children and children for which you have legal custody. This would not include parents, other relatives, domestic partners, significant others, your spouse or roommates.
Diagnosis - the health concern the doctor finds during the exam. This happens when the doctor identifies what kind of disease or condition you have.
Effective Dates - this is the date your insurance coverage begins and ends each year.
Employee Assistance Plan (EAP) - a program provided by an employer for their workers to use for many different types of services. For The Ōnin Group, this means our Teammates get free access to mental healthcare by phone 24/7/365.
Generic Prescriptions - these are prescription drugs that are not name brand and often cost less. It is like the difference between your store brand (generic) tomato sauce and Hunt’s or DelMonte (name brand) tomato sauce. You can usually decide which you prefer at the pharmacy.
In-patient Hospital - when you are admitted to the hospital for treatment.
In-Network - this means your doctor or hospital has a contract with your health insurance company for lower rates.
Insurance Policy - a contract between you and the insurance policy about who pays what on your medical bills.
Licensed Physician - a U.S. board-certified physician is licensed to practice medicine in the United States.
No Deductible Plan - this type of plan means your insurance pays part of the bill from the first time you use the service. With this type of plan, you will rarely pay the full amount of your bills for services covered by your insurance policy. You will pay a copay or a copay and your part of your coinsurance amount.
Office Visits - these are appointments at your family doctor’s office or general practitioner, not at urgent care, an emergency room or hospital. It may also be an appointment with your dentist or eye doctor as well.
Opt-out - choosing not to sign up for health insurance. With The Ōnin Group, you must call us at 833-236-7463 to let us know that you do not want any insurance benefits before the end of 30 days after your start date.
Out-of-pocket (Deductible) - this is your part of the medical bill that you must pay yourself.
Out-of-pocket Maximum - the most you will have to pay all year for medical expenses. If you have met your out-of-pocket maximum, you do not have to pay any more for copays, coinsurance payments or deductibles. After you pay this amount, your insurance will cover 100% of your medical claims for the rest of the policy year, although you will still have to pay for your premiums.
Out-of-Network - this means your doctor or hospital does not have a contract with your health insurance company, so your bills and copayments will be higher in most cases.
PPO - a preferred provider organization is a group of doctors, hospitals and urgent care facilities you can use for your healthcare needs. These providers have an agreement with your insurance company to treat you at certain rates for agreed upon services. If you use a PPO plan, you need to be sure you stay “in-network” to receive these lower rates. Your part of the medical bills will be lower than “out-of-network” would be. If you have questions about finding an “in-network” doctor, call the Advocate line at 833-751-1096.
Premium - how much you pay each month for your insurance, usually taken directly out of your check each week.
Preventative Services - basic services from a doctor to prevent illness or disease, like certain immunizations or health screenings, to keep you healthy.
Primary Care Provider - the doctor you see for most common illnesses, also called a general practitioner, family doctor or regular doctor.
Primary Care Visit - also know as an office visit; an appointment with your regular doctor for non-emergency appointments.
Referral - when your general doctor is unable to take care of your health issue themselves, and they send you to a specialist.
Specialist - this doctor is not your general doctor you see for colds and flus. A specialist helps you with specific issues in certain areas of the body. For example, an ENT (ear nose and throat) doctor will see you for severe allergies or related issues, but not for hip replacements. A cardiologist will see you if you have heart health issues or had a stroke. Their fees are usually higher than a general doctor’s would be, and you may be referred to a specialist if your regular doctor can’t solve your health concerns themselves.
Specialist Office Visits - an appointment with a specialist doctor.
Specialty Drugs - drugs which are not generic, but may be brand name, that are made for specific issues or require more involved formulation.
Treatment - the solution to your health issue, which can be what actions you must take to feel better and/or what medicine you will take.
Urgent Care - these offices are open later hours and sometimes on weekends, as well as during the week. They will see you without an appointment, like an ER, but charge lower rates and have limited services they provide. Rates are higher than your doctor’s office, but are a good choice when you are sick outside normal doctor’s hours or have a severe illness but not life-threatening and can’t wait to see a doctor. Our free teledoctor service is a good place to start if you are considering a trip to urgent care with a non-life-threatening illness.