Frequently Asked Questions

Active Employees

If my PPO physician refers me to a specialist that is not in the network, will the specialist's charges be reimbursed at the in-network rate?

Any out-of-network provider will be reimbursed subject to the $500 deductible and 70/30 co-insurance amounts, whether referred by an in-network physician or not.

If my provider is in-network when I elect to enroll in the PPO, but drops out of the network in the middle of the plan year, what are my options? Can I transfer to the Traditional plan?

You will not be able to change plan elections you made during the open enrollment period until the next open enrollment period. If your PPO physician drops out of the network, you will have to decide whether to find a new in-network physician or remain with your physician and be reimbursed at the lower out-of-network levels.

What is the length of the PPO contract signed by the Physician or the Hospital? How often do Physicians leave the network? How stable is the network?

The Blue Cross provider contracts are "evergreen" which means that once signed, the contract remains in place until the physician (or Blue Cross) decides to terminate the contract. In the event that the provider decides to terminate the contract, there is a 90-day period during which the provider must abide by the contract. This allows Blue Cross to notify policyholders of the change. Many providers who have decided to terminate their contracts notify their patients. Blue Cross has a very stable network. Their average turnover in participating providers is about 2%. Most of the physicians that terminate contracts are either moving or retiring.

What if I elect to enroll in the PPO and need to see a physician while out of state on vacation?

Blue Cross is a member of the Blue Card program through the Blue Cross/Blue Shield Association. This program allows you to have access to traditional or PPO networks nationwide. If you need to access a health care provider when out of state, you can call the Blue Card customer service at 800.810.2583 and they will assist you in finding a participating traditional, or PPO provider in the state where you currently are. That number will also be on the back of your new Blue Cross member ID card. You can also go to the Blue Cross web site at www.bcidaho.com and search for a provider in the state where you are.

If I am in an accident and am not able to choose a network hospital/provider, how will charges be reimbursed?

In an emergency, expenses will be reimbursed subject to the the in-network deductible and co-insurance amounts ($250 and 85%/15%). However, non-network providers are not bound by Blue Cross's participating provider pricing agreements, which means they may balance bill you. Also, you must notify Blue Cross within 24 hours of being able to respond so they can help direct any ongoing care to participating providers.

My spouse works for another employer and has Blue Cross coverage. If I cover him/her on my plan with the State, how will a claim on him/her be covered?

Benefits between the two plans will be coordinated as they have in the past. Your spouse's plan would apply benefits first on any claim he/she has and the State's plan would apply benefits on balances.

How long can I keep my child covered? Does he/she have to be in college to cover him beyond age 19?

Your unmarried child can remain covered to age 19. Beyond age 19, he/she can be covered up to age 25 as long as he/she remains unmarried and is eligible to be claimed on your most recent federal tax return.

Does the $20 office visit co-pay on the PPO apply to my deductible?

The $20 office visit co-payment does not apply to your deductible.

Do I pay the $20 office visit co-pay when I go to the chiropractor?

Chiropractic services are subject to deductible and co-insurance. The $20 office visit co-pay only applies to in-network PPO physician office visits.

If I go to a participating hospital, can I assume that the physicians in that hospital are participating as well?

Just because a hospital is a participating provider does not mean that any physician or other provider associated with the hospital (for example, anesthesiologists) are also participating. It is important that you check with these providers to determine whether they are participating or not. Non-participating out-of-network providers will be reimbursed at the lower out-of-network levels.

If I see a Nurse Practitioner (NP) or Physician's Assistant (PA) and the physician in the office or the clinic is participating, can I assume that the NP or PA is also participating?

A Nurse Practitioner or Physician Assistant works under the direction of a supervising physician. If the supervising physician is a participating provider, then the NP or the PA would be covered at the in-network levels.

What if my Doctor sends something to a non-participating lab and I have no say in where he/she sends the lab work? Will I be held to the out-of-network payment levels?

Any services provided by an out-of-network provider will be reimbursed at the out-of-network levels. Many physicians use several ancillary providers such as labs. Request that your physician send any of your tests to a participating provider.

What if I (or my dependents) are going in for surgery at a participating facility and the attending physician (such as the anesthesiologist) is not a participating physician and I have no choice in the selection? Will I still be reimbursed at the out-of-network levels?

Services provided by a non-network provider will be reimbursed at the out-of-network level. If you (or your dependent) are going in for a planned surgery, you will need to inquire whether the assisting physician, anesthesiologist, or any other medical professionals that may be in involved in the procedure are participating PPO providers. If not, request a participating provider.

Where can I find a complete listing of all of the services provided under the Traditional and PPO plans.

A detailed comparison of the benefits under the Traditional and PPO plans is available online through the employee portal at www.employee.idaho.gov or on the Group Insurance web site at www.adm.idaho.gov/insurance/.

If I am off work because of a job-related illness or injury and I am receiving workers' compensation benefits. What is the advantage to also applying for disability benefits through the Office of Group Insurance?

One advantage is that you are eligible to continue group medical and dental insurance coverage's for up to 30 months following your date of disability, provided your disability claim remains open. All you have to pay is the employee portion of the monthly premium. The employer portion of the premium is paid by the Office of Insurance Management.

In addition, basic life insurance benefits are continued, at no cost to you, for the duration of your disability claim. Supplemental Life insurance coverage is also continued for the duration of your disability claim, provided you pay the premium during the first six months of disability.

I did not enroll my spouse for coverage when I first enrolled several years ago. Is it possible to obtain dependent coverage now?

You may add eligible dependents to medical coverage at any time. If you submit an enrollment application outside your initial 60 day eligibility period, coverage will become effective the first day of the month following the date you sign the application form.

When is open enrollment?

Open enrollment is during the spring.

I have additional questions and I cannot find it in the materials available. Who do I contact?

For questions on your insurance, contact us at ogi@adm.idaho.gov or call 208.332.1860, or toll free at 800.531.0597.