FAQ - Health Insurance

 

-Children can be kept on insurance until they are 26 years old.  New in 2024:  Ohio legislation now requires all dependents to be covered on dental and vision until age 26.

 

Depending on your regular salary -Single is between $1,137.37 and $1,390.12 per year (between $47.39 and $57.92 per check) and family is between $3,070.87 and $3,753.29 per year (between $127.95 and $156.39 per check). 

If you waive insurance at the beginning of the year you do not pay these "co-insurance" amounts and get $500 or $1,000 in June.  If 12 or more members from the Teacher Unit Waive insurance then these amounts are increased by $1,000 and $2,000.

-When you use a network doctor you don’t pay anything out of pocket. For dental you pay 20%. When you go out of network, you pay the first $200/$400 (single/more than one person), then you pay coinsurance of 20% with no maximum. In addition, when you go out of network, you risk being billed for the amount that MMO didn’t pay. For instance, you have work done out of network and the bill is $600. MMO decides that the work is only worth $200. You could get stuck paying the balance.

 

-For claims not paid by MMO you have the right to appeal. Usually this can be done on the computer through the MMO website (www.medmutual.com), or you can download the form and send a hard copy.    A narrative sent along with the appeal can help explain what happened.   A medical team reviews the appeal. Sometimes the appeals work, sometimes not. If you get no satisfaction through the appeals process, it is possible to take your appeal to the Ohio Insurance Board, where the case will get decided by an independent medical review team based on our benefits.  Our office can help, if needed.

 

Our dental plan pays up to $3,300 per calendar year for preventative and restorative care. The orthodontia limit is $3,300 per mouth.  Preventative care is covered with no copay, but all other dental and orthodontia are paid 80/20 - where you pay 20% of the cost and insurance pays the remainder (until the limit kicks in and you pay the balance).

 

-We have a straight dollar benefit of $70 per year for an exam. We also have a set amount of $180 per year for single frame lenses; $205 for bifocals, and $230 for trifocals. As of January 1, 2023, progressive lenses are now covered at a rate of $205. Strangely enough, our plan does not cover lenses without frames.  Contacts are covered up to $130

 

-As of February 2021 if you buy generic the co-pay is $5. If you buy brand it is $15. If you buy brand when a generic is available it is $50. If you require brand when generic is available because of a medical problem with the generic, then there is a process that your doctor can go through to get your preferred prescription approved at the $15 rate.  If you are on maintenance drugs and use mail order you have the double the co-pays, but you get a 90 days supply instead of a 30 day supply.  For a very few members there are specialty drugs that require that you use a special mail order pharmacy.

 

Annual hearing exams are covered to $70.  Every 36 months we have a $1,000 hearing aid benefit per ear.

-You can call payroll. You can call customer service at MMO. Or you can order one online using your MMO account.  If you use the mobile app on your phone you will not need a card - it creates one for you to use.

 

-You will have coverage through August 31. You earn your benefits for the summer during the school year.

 

-The Family Medical Leave Act is a federal law that provides protection for workers who run out of sick leave. It provides up to 12 weeks of medical coverage for those who are eligible. To be eligible you have to first have a medical reason to be away from work, mostly the same as the criteria for using sick leave. When using sick leave for an extended period you are actually using FMLA, but it is transparent to us. Sick leave and FMLA leave run concurrently, so you don’t get an additional 12 weeks after you run out of sick leave. This is one that varies from individual to individual, so if you think there might be an issue you should call our union office before filling anything out.  (Link to FMLA specific info)

 

The No Surprises Act went into effect in 2022.  This act requires medical facilities to inform patients of the worst-case-scenario for all medical bills.  These calls come before the medical facility processes your insurance, so you should not pay at the time of the phone call.  Tell them that you will wait until the bill comes in the mail.  This will allow all medical claims to go through your insurance, and you will receive an Explanation of Benefits (EOB) stating what you owe for the procedure.

 

-First off, if you or a family member is having an emergency you should get to the nearest facility that can help you. When your life is in danger there should be no worry about where you get help. Emergency room visits are paid at 100% ALTHOUGH that is 100% of what MMO thinks the provider deserves. If you go to some remote areas that are not connected to any network it is possible that you will be balance billed and there is not a lot you can do about it. That being said, if you have a non-life threatening emergency, you can call the number on the back of you MMO card to see where they suggest you go in an extended network, if possible. Also, if you go to a non-network facility for the emergency, DO NOT GO BACK FOR FOLLOW UP VISITS. Find somewhere in network to go, if possible. Call us when you get stuck with the bills and we will try to help sort it out.

-if you need to see a doctor when you are out of town and it is NOT an emergency, then consider using Express Care Online, our telemedicine app.

 

Medical bills

There are a few reasons to have to pay out of pocket for medical services.  The main reasons are as follows:

1. The service is not covered. 

If the service is not covered, then you are on the hook for it.  It is best to prevent these types of problems by knowing your benefits, being familiar with the certificate of insurance that is available through the MMO website, and getting prior approval for services when it is required.  If you get a hearing test because you believe you are losing hearing, most likely, it will not be covered.  If you get a hearing test as a way of diagnosing some other illness it may.  Know your benefits before you use them.

2. The service was not coded properly. 

Often the problem is not the way a claim was processed by the insurance company, but the way it was coded by the provider.  Most often you can ask your provider to resubmit the claim with a more appropriate code and it will be covered.  For instance, cholesterol lab work is not covered if it is coded as “routine,” yet if it is resubmitted with a diagnostic code that included hypertension it probably will be covered.

3. No claim was submitted to insurance.

If MMO did not get paperwork, they will obviously not pay anything.  Call the provider and see what they did.  If they are not helpful in fixing the problem, then perhaps you should not go there again.

My medical bill was sent to collections

Sometimes people don’t realize they have to pay a medical bill and it eventually ends up being sent to a collections agency.  If you truly owe the money then you should pay it before it continues to mess up your credit rating.  If you believe you do not owe the money, then don’t pay anything, but call the collection agency and tell them you will be working with your union to get the bill settled.  This should buy some time.  Call us as soon as possible so we can help to figure it out.

 

updated 2.24