Metal plans are the tiered system used by the Affordable Care Act to help you determine the percentage of health care expenses that will be paid by the plan. There are four tiers: Bronze, Silver, Gold and Catastrophic. Bronze is the more affordable metal plan tier, but the Gold metal plan tier offers more comprehensive coverage.

When the Obama Administration announced the transitional relief policy that allows individual and small group, fully insured, non-grandfathered policyholders to maintain their 2013 medical coverage through 2014, it indicated it would assess the policy and the specified timeframe. On March 5, 2014, the Centers for Medicare and Medicaid Services (CMS) announced it will extend the transitional policy for two years, for policy years beginning on, after or before Oct. 1, 2016, with the possibility of adding a one year extension.

The transitional relief also applies to large businesses that currently purchase insurance in the large group market if, as of Jan. 1, 2016, they will be redefined by the Affordable Care Act (ACA) as small businesses purchasing insurance in the small group market.

As with the earlier transitional relief policy, State governments and health insurance issuers will have the option to offer the transitional relief or not participate. Policies offered under the transitional relief will not be considered out of compliance with certain ACA market reforms, such as:

• Adjusted community rating for health insurance premiums
• Guaranteed availability of coverage
• Guaranteed renewability of coverage
• Prohibition of pre-existing conditions exclusions in the individual market
• Coverage of the 10 Essential Health Benefits categories established by the ACA
• Clinical trials participation
• Non-discrimination with respect to health care providers

In-network providers/facilities are providers contracted with Cox HealthPlans. Services provided by in-network providers will be subject to the in-network benefits, which means you will pay less and receive the highest level of benefit under the plan. Cox HealthPlans services 26 counties in southwest Missouri. To locate a provider including specialists and pharmacies, visit our Provider section. 

The deductible is the amount an individual pays for their medical services each calendar year before Cox HealthPlans begins sharing the costs for their medical services.

The office visit copay is the fee you pay for each visit to the doctor’s office. This is typically the only payment you will make up-front. All other payments owed should be billed to you by the provider after the claim has been sent to Cox HealthPlans and processed. Office visit copays are applied to the coinsurance maximums, not to the plan deductibles.

If your plan has the standard in-network office visit copay, this office visit copay covers the physician’s consultation fee. All other services (for example, diagnostic X-rays, lab work, etc.) will be subject to the in-network deductible and coinsurance. Out-of-network office visits are subject to the out-of-network deductible and coinsurance.

If your plan has the inclusive in-network office visit copay, this copay covers those services provided and billed through the physician’s office. ALL other services (for example, diagnostic X-rays, lab work, etc.) not billed through the doctor’s office will be subject to the in-network deductible and coinsurance. Out-of-network office visits are subject to the out-of-network deductible and coinsurance.

eVisits are a new convenient way of visiting with your physician from the comforts of your home or office—without time or inconvenience of travel to the physician’s office or spent in waiting rooms! This benefit is currently available through certain Cox physicians; please verify with your physician that he/she offers this service. 

Once established as an existing patient of a participating health care provider, you may log in through your computer to your CoxHealth Express account to access the eVisit feature. For a $10 copay, members may communicate with their physician safely and securely with responses from their physician within 24 hours (or sooner). Please contact our Member Services Representatives at 1-800-205-7665 for eVisits and participating providers.

Coinsurance is the percentage of cost-sharing between you and Cox HealthPlans for your medical expenses. Coinsurance applies after you have met your deductible if you have additional health care needs within the same calendar year. Your health plan will always have a maximum or cap on the amount of total coinsurance you are responsible for each calendar year.

The in-network coinsurance responsibility after satisfaction of the in-network deductible is either 0%, 20% or 30% of the remaining eligible expenses depending on the benefit plan selected. “Eligible” refers to the amount of a service charge that the insurance company will allow a contracted physician to bill a member. If the contracted physician bills over this allowed amount, the member is not responsible for the additional cost above the allowed amount and the physician is contractually required to “write-off” that overage.

The out-of-network medical coinsurance responsibility after satisfaction of the out-of-network deductible is either 30%, 40% or 50% of “reasonable and customary” (R&C) or allowed charges. Because out-of-network physicians are not contracted with Cox HealthPlans, they have the right to charge more than the allowed amounts. Therefore, a member could be responsible not only for the plan percentage of the R&C charges, but also 100% above any remaining charges above the R&C amounts.

Cox HealthPlans will cover the services outlined in the Patient Protection and Affordable Care Act (PPACA) with no cost share to the member—Cox HealthPlans will pay 100% of the approved charges for these services. A full list of no cost preventive services, along with the preventive service codes can be found by logging into your Member Online Access. 

To log in you will need your member number located on your ID card to register. Once logged in, select “My Information” on the left hand side of the screen, scroll down to the middle of the page under “Additional Benefits” and select the “Preventive Service List” for a complete listing of services.

A Benefit Booklet is a detailed description of the provisions and limitations of the plan.

Our Medical Management Team stands ready to assist any members currently undergoing treatment, are pregnant, or needing/currently using Durable Medical Equipment, etc., to transition their care from physicians and facilities that are outside of the Cox network, into the Cox network.

It is always in your best interest if we can be proactive with this assistance, so we ask that you contact our Medical Management Team beforeyour policy goes into effect if at all possible. Additionally, they can provide assistance by working with you and your physician if you are taking medications that fall under the Pharmacy Benefit Limitations List noted below or medications that are excluded from the Formulary.

Members needing assistance such as the above may call (417) 269-2813 to speak with a Nurse Case Manager. Our goal is to help individuals experience the least amount of disruption to their care as possible, so please take advantage of this service!

Prior to the effective date with Cox HealthPlans, please refill any prescriptions on which your supply may be running low to ensure you have your medication when needed. Although your pharmacy benefits should be implemented on your effective date, having a few days’ supply or even one full refill on hand when you obtain your first prescription fill through Cox HealthPlans may help you through the transition in the event of any unforeseen delays.

Members can view the current prescription drug coverage on our Prescription page. 

PPO Plans are traditionally more flexible than HMO Plans. Costs are controlled through provider contracts, and provider networks are broader. Benefits under these plans are generally comprised of deductibles and coinsurance, and sometimes copays.

A U.S. regulation that gives patients greater access to their own medical records and more control over how their personally identifiable health information is used. The regulation also addresses the obligations of healthcare providers and health plans to protect health information.

For care outside of our 26-county service area, Cox HealthPlans provides access to additional in-network providers through First Health Network, one of the leading preferred PPO networks in the United States. Today, there are nearly 490,000 First Health providers, hospitals and other health care providers in urban, suburban and rural areas throughout the United States including the District of Columbia.

Members are not required to use the First Health Network for unplanned or emergency treatment while outside the service area, but doing so will help limit the out-of-pocket expenses and maximize their benefit level. Providers in the First Health Network who are within the Cox HealthPlans 26-county service area will not be recognized as in-network providers.

PPO members are served by the First Health Network in three ways:

• For members who reside outside of Cox HealthPlans’ southwest Missouri network area, First Health will serve as the primary PPO network to access in-network benefits where the member lives; the First Health logo will be located on the front of the ID cards for these members.
• For members who reside within Cox HealthPlans’ network area but are seeking care outside of southwest Missouri, providers can be accessed via First Health for in-network benefits.
• Dependent children who are attending college outside of southwest Missouri may also access providers in the First Health Network for in-network benefits.

To find a provider in the First Health Network, click here or go to www.firsthealth.com, then select “Locate a Provider/Search by Client” and enter login ID: COXHP. You can also call First Health at 1-800-226-5116 Monday through Friday from 7 a.m. to 7 p.m. (CST), or Cox HealthPlans Member Services Toll Free at 1-800-205-7665 Monday through Friday 8 a.m. to 5 p.m. (CST).

A twelve month period beginning January 1 ending December 31.

Identification cards are mailed to all members’ homes after enrollment paperwork has been submitted to Cox HealthPlans, typically within 5-10 business days from the date of enrollment in our system. Benefit booklets, the schedule of benefits and temporary identification cards are available through the Member Online Access or you can contact our Member Services Department directly at 1-800-205-7665.