You can change your PCP or PCD at any time. Once you select your new doctor or dentist, you must contact your medical or dental plan to request the change which typically takes effect the first of the month following the date you made the request.

You can log on to your health plan’s website and verify that your doctor in the online provider directory, or call your health plan’s customer service center using the number provided on the back of your ID card.

Log on to your health plan’s website and use the search features in the online provider directory, or call your health plan’s customer service center using the number provided on the back of your ID card to request a hard copy provider directory.

Having a baby is a “qualifying event” which means you can enroll your newborn outside of the Open Enrollment period. To ensure enrollment, the change must be submitted within 31 days of the event.

If you do not enroll for medical insurance when you are first eligible, you will have to wait until the next Open Enrollment period to sign up for coverage.

A change in your spouse’s employment is a “qualifying event” which means you and/or your spouse can enroll for benefits under the new employer’s plan. If you and/or your spouse would like to drop coverage under your employer’s plan and enroll in your spouse’s plan, you must notify your employer within 31 days of the change in employment.

Out-of-Network services are those obtained from a doctor, facility or lab that is not contracted with your health plan. Some plans require you to get all services In-Network in order to receive benefits. In that case, Out-of-Network services would not be covered or would be covered for a lower amount than a visit to an In-Network provider.

A “qualifying event,” also known as a “qualified change in family status,” is an event in your life that allows you to change your benefit elections outside of the annual Open Enrollment period. If you are enrolled in the company’s benefits program, you generally may change your benefit elections when you experience one or more of the following family status changes: Change in legal marital status (i.e., marriage, divorce, death, legal separation or annulment); Change in the number of dependents (i.e., birth, death, adoption or placement for adoption); Change in your or your spouse’s employment status or employer-provided coverage; Change in dependent eligibility; Change of residence; Receipt of a judgment, decree, or order to provide coverage; Changes resulting from a family medical leave; Enrollment in Medicare or Medicaid; Significant cost or coverage change (although such a change does not permit a modification to your health flexible spending account). For family status changes, the coverage change you make must be consistent with your qualifying event. You may be required to provide documentation, such as a birth certificate or marriage license. To ensure enrollment, the change must be submitted within 31 days of the event.

A Calendar Year deductible is the amount you pay towards medical expenses each year before the plan starts paying benefits. A Calendar Year deductible is effective from January 1 through December 31 and starts over again the following January 1.

A Non-Participating Provider is a doctor, facility or lab that is not contracted with your health plan. Some plans require you to utilize only participating providers in order to receive benefits. A visit to a Non-participating provider would not be covered or would be covered for a lower amount than a visit to a participating provider.

A Participating provider is a doctor, facility or lab that has contracted with your health plan to provide services to covered members. Some plans require you to utilize only Participating providers in order to receive benefits. Others allow you to utilize non-participating providers but provide a lower level of benefits or higher out-of-pocket costs.

A Preferred Provider Organization (PPO) is a combination of in- and out-of-network medical providers. In-network doctors and facilities have agreed to offer services at reduced, contracted fees. You can choose between in- and out-of-network benefits each time and generally do not need referrals or Primary Care Physician authorization for specialists. Claims must be led by you for out-of-network services. To receive in-network benefits, you must use the provider’s network of doctors and facilities. There are annual deductibles, copays and coinsurance. If you visit doctors and hospitals within the provider network, you will typically benefit from lower costs.

Pre-admission certification is a review process that verifies the medical necessity and appropriateness of a non-emergency hospital stay and related procedures. Please refer to your plan’s Summary Plan Description to determine whether Pre-Admission Certification is required for any non-emergency hospital stay and related procedure.

A Referral is an authorization provided by a Primary Care Physician or Specialist to allow you to access additional benefits or services. This is typically required of HMO and POS plans and may be in either written or electronic format.

An EOB is a statement a member receives that describes how a claim was processed for benefits, including the amount the member owes, if any, for services rendered.

An Employee Contribution is the amount that you pay on a monthly or bimonthly basis to cover your share of the cost of insurance.

A Health Maintenance Organization (HMO) is a restricted group of doctors and facilities that have contracted with an insurance company to offer services at a discounted rate. When you enroll, you and your eligible dependents each select a Primary Care Physician (PCP) to coordinate all your medical care within the provider’s network. (Kaiser Permanente does not require a PCP, but all services must be provided by Kaiser physicians at Kaiser facilities. Otherwise, you won’t be covered, except in emergencies.) You must use the HMO’s network of doctors and facilities every time you receive care. Services are generally paid for with copays. There are generally no deductibles.

Coinsurance is the percentage or amount members are required to pay for covered services. Coinsurance is a percentage of the allowed benefit or cost. For example, if your coinsurance is 20%, and the allowed cost is $100, your coinsurance cost would be $20.

The Out-of-Pocket Maximum is the maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a given year for covered expenses. Once the out-of-pocket limit is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period.

You can add your spouse or child to your health insurance plan during Open Enrollment, the period of time held once each year to allow changes to your benefit elections. The only time you can make a change to your benefit elections outside Open Enrollment is if you experience a “qualifying event.” See also, “What is a qualifying event?” for details on when a change in enrollment would be permitted outside of Open Enrollment.

Generally you can change your benefit plans only during your employer’s Open Enrollment period, held once each year. However, if you experience a qualified change in family status, or “qualifying event,” you may have the opportunity to change your benefit elections outside of Open Enrollment. See also “What is a qualifying event?” for details on when a change in enrollment would be permitted outside of Open Enrollment.