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4J Benefits and Wellness Newsletter – December 2016 – Issue 292

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Prepared by Julie Wenzl • 541-790-7682 • wenzl@4j.lane.edu • December 7, 2016 • Issue Number 292


Your Moda/OEBB insurance plan covers certain preventive medical care at 100% when you see an in-network provider. If you seek care for something other than preventive care, then your claim will be subject to copayment and/or deductible and coinsurance. Not sure what those terms mean?

  • Preventive Healthcare: This includes, but is not limited to, evidence-based services rated A or B by the United States Preventive Services Taskforce, immunizations recommended by the Advisory Committee on Immunization Practices of the Center for Disease Control and Prevention (ACIP), and preventive care and screenings recommended by the Health Resources and Services Administration. Members may call Customer Service to verify if a preventive service is covered at no cost share: 866-923-0409.
  • Claim: The bill a provider or member submits to the plan to be reimbursed for covered goods or services.
  • Co-payment (or co-pay): A fixed dollar amount (e.g., $30) paid by the member to the provider at the time of service.
  • Deductible: The amount a subscriber pays for covered goods or services before the plan begins to pay claims. Deductibles are accumulated on a plan year basis. The deductible applies separately to each member, but no family will be required to satisfy more than the total family deductible.
  • Plan Year: A period of 12 consecutive months. Currently, the OEBB Plan Year is Oct. 1 through Sept. 30. Benefit year refers to the twelve-month period where deductibles, out-of-pocket maximums, or any annual benefit maximums accrue and apply. OEBB’s benefit year and plan year are the same.
  • Additional Cost Tier: The Additional Cost Tier (ACT) refers to select procedures on Moda Birch, Cedar, and Dogwood medical plans.
  • Out-of-pocket maximum: The maximum you will have to pay out of your pocket for covered services. Out-of-pocket maximums are calculated on an individual basis and are accumulated on a plan year basis.

Not all expenses apply to the out-of-pocket maximum. On a PPO plan, the maximum out-of-pocket includes medical deductibles, coinsurance and copays. It does not include ACT copays, pharmacy expenses, disallowed charges or balance billing amounts for out-of-network providers. On a Synergy plan, the maximum out-of-pocket includes medical and Rx copays (excluding ACT), coinsurance and deductibles. It does not include ACT copays, disallowed charges or balance billing amounts for out-of-network providers.

The following costs do not accrue toward the out-of-pocket maximum and members must pay for them even after the out-of-pocket maximum is met:

  1. The out-of-pocket expenses for bariatric surgery not performed at a Center of Excellence facility, or out-of-pocket expenses above the Center of Excellence $20,000 benefit maximum
  2. The out-of-pocket expense for a sleep apnea appliance above the $1,800 benefit maximum per appliance
  3. The out-of-pocket expenses for hip and knee replacements above the $25,000 benefit maximum (applies to PPO plans only)
  4. Cost containment penalties (applies to PPO plans only)
  5. Disallowed charges

Please note that the out-of-pocket for pharmacy expenses works differently depending on whether you are enrolled in a PPO plan or a CCM (Synergy) plan.   For more information please refer to the Pharmacy FAQ: https://www.modahealth.com/oebb/faq_ben_rx.shtml

  • Maximum Cost Share: The maximum cost share applies to Moda Birch, Cedar, and Dogwood medical plans and is different than the out-of-pocket maximum. This plan year limit includes ACT copays, pharmacy copays and coinsurance, as well as the eligible medical expenses that accrue toward your in-network out-of-pocket maximum. Once the maximum cost share is reached, the plan covers all eligible medical and pharmacy expenses at 100 percent.
  • Coinsurance: The cost of a covered service that is shared by the plan and by the member after the deductible has been met, typically expressed in percentages; e.g., 80% plan and 20% member. The provider typically bills the member after the plan has paid.
  • Network Information: In-network benefits are those delivered by in-network providers; out-of-network benefits are those delivered by out-of-network providers. By using the services of an in-network provider, members will have a higher level of benefits. Members may choose an in-network provider from the network directory, which is available on myModa under “Find Care,” or by contacting Moda Customer Service (866-923-0409) for assistance. Your member ID cards identify any applicable network(s).

You can find information about your insurance coverage, including plan summaries and full plan books, on the Moda website for OEBB members: https://www.modahealth.com/oebb/.

It is important to keep in mind the real purpose of medical insurance. Its intended purpose is not to pay every medical expense following the outlay of a specific and ideally low monthly premium. Its purpose is to prevent the economic catastrophe that could occur were it not in place. While none of us is expected to be happy about the escalating costs of health care and medical insurance, we need to remember that our current coverage here at 4J protects us against the financial disaster that a serious illness, injury, or hospital confinement could otherwise mean.


You have until December 31, 2016, to submit receipts for unreimbursed health related or dependent care expenses incurred during the October 1, 2015 – September 30, 2016, plan year.

Up to $500 of remaining funds in your FSA for unreimbursed health related expenses will rollover automatically after December 31, 2016. Any unused money left in your FSA for dependent care expenses at the end of the plan year will be forfeited, as per IRS regulations.

If you have any questions, the PacificSource Administrators Customer Service number is 541-485-7488. You can access the PSA website at http://psa.pacificsource.com/PSA/.


The 4J Wellness Clinic will be closed during part of winter break: December 26 – 30, 2016. Regular clinic hours, which resume January 2, 2017, are Monday through Friday, from 9:00 a.m. – 6:00 p.m. The clinic is closed for lunch from 1:00 – 2:00 p.m. The phone number for the clinic is 541-686-1427.


Like all licensed employees, I will be out of the office for winter break December 19, 2016, through January 2, 2017.

For questions regarding Moda Health benefits or claims, contact:

  • Moda Medical Customer Service – 866-923-0409
  • Moda Dental Customer Service – 866-923-0410
  • Moda Pharmacy Customer Service – 866-923-0411
  • https://www.modahealth.com/oebb/

For questions regarding Willamette Dental Group benefits or claims, contact:

  • Appointment Center: 1-855-433-6825, Option 1
  • Member Services: 1-855-433-6825, Option 3
  • Member Services: memberservices@willamettedental.com
  • http://www.willamettedental.com/oebb

For questions regarding eligibility, contact OEBB:

To access the Employee Assistance Program:

For questions regarding life or long term disability insurance:

Have a wonderful winter break!

The information in this newsletter has been summarized. It is presented as information – not advice or counsel. In all instances, the benefits, conditions, and limitations as outlined in the 4J Master Contracts prevail over this representation. Please refer to your Benefits booklet or master contracts available at the District offices for additional information regarding your benefits plans.

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