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APWU 133

    APWU health insurance premiums with and without APWU special rates.

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    Election and address information

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    Attention members, nomination for office

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    LOCAL ELECTION NOTICE

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    Health insurance info

    Apwu133
    By Apwu133,

    In my time as the Health Plan Coordinator, I have had a number of people tell me that insurance terms and insurance in general is very confusing. I don’t disagree with this. The last job I worked before coming to the Post Office in 2013 was Wells Fargo TPS (now HealthSmart). We provided customer service for the State of Alaska Employee insurance. We spent 6 weeks in training before they ever let us pay a claim or take a customer service phone call. Understanding insurance and how it works is VERY important. I can’t tell you the number of heartbreaking phone calls I received from recent widows and widowers who didn’t have any idea what they were doing because their partner had taken care of all of it. Below I have defined some common insurance terms that should apply to most insurances, not just the APWU Health Plan offerings, to help clear up confusion. Check back next week for some plan highlights on the High and Consumer Driven Options! 

     

    Premium – this is the amount you pay to participate in an insurance plan. This is the amount that comes out of your check each pay period.

     

    Deductible (DED) – this is the amount you need to spend out of your own pocket before the insurance benefits kick in. Generally speaking, the lower the deductible, the better. 

     

    ***These two definitions can be the MOST important things to look at. What the insurance plan covers may not matter if your Deductible is so high that you never reach a point where insurance will kick in.***

     

     

    I also like to point out to people the big picture. Getting an idea of what you have to spend out of your own pocket before Insurance actually kicks in can be a real eye opener. I nearly switched to the High Option for the better Prescription coverage before I did the math and figured outI’d still have to spend nearly $2,000 more over the course of the year. 

     

    Self Only

    High Option (HO)

    Consumer Driven Option(CDO)

    Yearly Premium Total

    $2746.50

    $403

    Deductible

    $500

    $1000 (after PCA)

    Total before Insurance kicks in

    $3,246.50

    $1,403

    This chart assumes you meet the qualifications for the CDO discount, meaning you have had a Federal Employee Health Benefit Plan (the USPS BCBS plan for PSEs is NOT a FEHB/PSHB plan) for one year, are a career employee, and are full dues paying member of the APWU. Retirees do not receive the discounted price. Non-members can still have either insurance plan, but they pay full price and must pay a yearly Associate Fee of $35, which is billed separately in April of each year. 

     

     

    If you want to apply this math to another plan, take your bi-weekly premium x 25 (There are 25 pay periods in 2025) and then add your deductible to that number. 

     

     

    Please keep in mind that while these numbers are important, they are NOT the only thing to look at when making a choice on what insurance to carry. Think of what your needs may be in the next year. Do you have small children, need diabetes coverage, have behavioral health concerns, or a chronic health condition? Are you generally healthy and just looking to avoid a large emergency bill? Those make a big difference in what kind of plan you want. 

     

     

    ***An aside. The lower your Deductible, the higher a Premium you will pay, typically. If you are paying both a high Premium AND a high Deductible, you may want to reevaluate your insurance.***

     

    ***Health Insurance plans cover a lot of “Wellness checkups” at 100%. This means your yearly checkup for both adults and children and most immunizations can be at no cost to you. This can also include preventative care and screenings, as well as maternity care and contraception. ***

     

    In-Network – Providers and facilities that participate in the Insurance network. 

     

    Out-of-Network  - Providers and facilities that do not participate in the Insurance network. While these claims may still be covered, they will be covered at a higher cost to the member. 

     

    Out-of-Pocket (OOP) – this is a running total of all the money you have spent on insurance claims throughout the year.  This amount includes your deductible, and if you are on the CDO plan, includes spent monies from the Personal Care Account (PCA). Plans usually have a separate total for In-Network OOP and Out-of-Network OOP. 

     

    Out-of-Pocket Maximum/Catastrophic Maximum – once you reach this limit, the plan will pay 100% of covered claims.  

     

    **High Option and the Consumer Driven Option both have a Self In-Network OOP Maximum of $6,500 and Out-of-Network of $12,000. On Self + One or Self + Family, the In Network OOP Maximum is $13,000 and Out-of-Network is $24,000. That is a huge difference. United Healthcare (the carrier for both plans) is the largest in the nation, with over 1.7 Million providers nationwide participating in the network.

     

    Plan allowance/Allowed Amount/Reasonable and Customary – these terms limit how much a provider can charge for a particular service. These amounts can vary based on where you live. 

     

    Patient Responsibility – This is the amount you are responsible for. Please always double check your claims and make sure they are being paid properly by the insurance and that your doctor’soffice is billing you correctly. Doctors’ offices are dealing with dozens of different insurances that all do things a little differently. Do not assume that they are perfect at their jobs.

     

    Co-insurance – a percentage that the member is responsible for after insurance pays. (e.g. your patient responsibility for most covered costs on the CDO is 15%)

     

    Co-pay – a set amount due at the time of service. Can vary based on provider type. (e.g. an office visit has a $25 dollar co-pay for an office visit)

     

    Personal Care Account/ Health Savings Account  In the CDO, this is money placed into the members account annually for covered health claims by the insurance plan. In other health plans, this money is typically the members money that they invest themselves. 

     

    **Because the insurance provides this money, not you, you are still eligible for a Flex Savings Account (FSA)if you wish to have one.**

     

     

    Explanation of Benefits (EOB) – This is the paper you get in the mail from Insurance that states “This is not a bill. Typicallyit will list the charge, what was allowed or not allowed, any discount given, what the provider was paid, and what your patient responsibility MAY be. It is a breakdown of how your claim was handled by the insurance. Again, I always recommend taking time to look over these and make sure you understand what is going on. Providers mess up, and the people at insurance paying the claims mess up. We are all human. This is your money and your health. Make sure it is working for you! In the same vein, NEVER just pay the bill your provider sends you. Compare it to the EOB that your insurance sent you. Make sure they are not charging you for something your insurance paid out of your PCA/HRA (which can happen quite a bit on the CDO plan). I personally have had to call my doctor’s office and help them “find” the payment my insurance already sent. 

     


    That covers the basics. If you have more questions, feel free to reach out to me! 

     

     

    Kayla Reynolds


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