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Frequently Asked Questions

Frequently Asked Questions
What is a high deductible health plan?

An HDHP covers health care services (office visits, hospital tests, therapy, prescriptions, etc.) that are not considered preventive only after an individual or a family has met the deductible. The deductible is usually waived for preventive care services. Typically, an HDHP features a lower insurance premium and a higher deductible than traditional plans. WHA offers some HDHP plans that include a health savings account (HSA), but not all HDHPs are HSA compatible.

What's attractive about an HDHP?

You pay a low monthly premium while still getting no-cost preventive care. If your HDHP is HSA compatible, you can use your HSA to pay for covered services.

How does an HDHP work?

You have a deductible to meet each benefit year. The deductible must be satisfied before your health plan will cover the expenses for covered services received.

What are deductibles, copayments and the annual out-of-pocket (OOP) maximum?
  • Deductible: Your health care plan has a deductible. The deductible is the amount you pay each year for most covered medical and prescription services and supplies before WHA will cover those services. The premium and the deductible are separate. Your premium is the monthly amount you pay to the health carrier for benefit coverage. Premiums do not count toward the deductible in your health plan.
  • Copayments: Your plan may also require you to pay copayments after you meet your annual deductible. These are typically smaller dollar amounts or percentages for covered services.
  • OOP Maximum: Once your deductible and copayment costs reach your annual OOP maximum amount, you are done. WHA will cover 100 percent of your covered services for the remainder of the calendar year.
What is the amount of the deductible that I have to meet under a WHA HDHP?

Deductibles vary depending on the plan you selected and whether you are enrolled as a self-only, an individual within a family or as a family. For specific comparisons of the deductible within each plan, look at the copayment summary of the plans you are interested in.

How do I know how much my services are going to cost?

Western Health Advantage partners with leading service providers to ensure that our members get the best rates available. This means that you’ll enjoy consistent savings on your health care services and supplies. 

Use our medical service cost estimator to see what is the estimated cost of a specific service you intend to receive.

What types of expenses apply toward the deductible in an HDHP? Will my prescriptions count toward my annual deductible/OOP maximum?

Covered non-preventive medical and prescription expenses apply toward the deductible, as described in the plan. Examples include charges for office visits with doctors, inpatient and outpatient hospital services, diagnostic tests, and covered prescription drug expenses.

Payments you make for prescriptions covered under your plan will apply to your deductible and OOP maximum. It’s important to note that covered prescriptions must be obtained from a participating provider and must be run through WHA’s contracted pharmacy benefit manager in order to be applied. Prescriptions obtained from a non-participating provider are limited to emergent situations or urgent situations arising outside of WHA's service area.

What would be the most I would have to pay out-of-pocket under the HDHP in a calendar year?

The answer depends on whether you are enrolled as self-only coverage or an individual within a family/family coverage, and your specific plan. For specific comparisons of maximum out-of-pocket amounts, look at the copayment summary of the plans you are interested in.

Are there any benefits under an HDHP plan that have no cost to members?

Yes, routine preventive care services are covered at no cost to members (and don’t apply to the deductible). Because preventing illness and disease will save you money, be sure to go for preventive screenings and annual checkups. The advice you get from your provider at these visits could lead to a healthier lifestyle, which can avoid costly treatments.

What is an accumulator?

Your accumulator stores all of your medical expense claim data. It adds the amounts so you can see how much has been applied towards your deductible and out of pocket expenses.  

Once you create a MyWHA account you will be able to login to MyTools, click on View Your Accumulator to get an up-to-date record of your claims and deductible/OOP amounts.

Your accumulator is in a spreadsheet format and can be read from left to right.  It provides your member ID, the member name, the service description, the Process Date of the Claim, the Date of Service of the Claim, total charges, the deductible amount (this is the amount owed by you), Copay Amount (if applicable), the Family Deductible Running Total and Family Out-of-Pocket Maximum.  These last 2 columns show when the deductible and out-of-pocket maximums have been met.

What do I pay after I have met the calendar-year deductible?

After you have met the calendar year deductible, you will be responsible for paying the copayment or coinsurance for medical services and prescription medications in accordance with the specifics of your plan, up to the out-of-pocket maximum.

Is there a cap on what I am required to pay after meeting the deductible?

Yes. The specific amount depends on what plan you chose and is referred to as the annual out-of-pocket maximum. For specific comparisons of maximum out-of-pocket amounts, look at the copayment summary of the plans you are interested in.

What are some tips for managing my HDHP?

If you have an HDHP, you should be proactive in managing your health care benefit. Become a smart shopper. Finding out the cost of a service or procedure in advance can help you better plan your healthcare expenses. Also, ask your health care providers if they will prescribe less expensive medications or treatments, such as generic drugs. You should keep records and copies of your healthcare receipts to keep track of your healthcare expenses, so that you know when you have met your deductible.

What if I don’t have internet access or feel comfortable using the internet to view my claims info?

You can contact Member Services and they can print you a copy of your current accumulator.

What do I do if I’m being billed or I paid for claims that are not on the accumulator? 

Contact Member Services department and they can assist you.

How do I know if my claims have been paid and/or processed correctly? 

Your bills from your providers should match the amounts listed on your accumulator.  If they do not, you should  contact Member Services for further assistance.

How does WHA determine which claims apply toward my deductible and/or OOP?

Claims are applied to your deductible and OOP maximum in the order of WHA’s claim process date. As a result, it’s quite possible that your claims will be applied in a different order than the one in which you actually saw your provider(s). All claims for covered services that WHA processes prior to the date on which you meet your deductible will count toward your deductible and OOP maximum.

If your plan has a higher OOP maximum, once your deductible is met, your services will incur a copayment and those copayments will count toward your OOP maximum, as well.

Please note that one visit may result in multiple claims, which means you could receive multiple bills for that visit. For example, if you have an outpatient surgery, you may be billed separately for the facility, surgeon and anesthesiologist. Again, it is the process date of these services that determines the order in which claims are applied to the deductible or OOP maximum.

Should I pay for my services upfront?

It is generally a good idea to wait for a bill from the provider.

What if a provider is insisting on collecting funds upfront?

Ask the provider if they can send you an invoice after a determination has been made by WHA and the medical group of the appropriate allowed amount you are responsible for so you can be assured of being billed the exclusive WHA member rate.

How do the medical group and providers know not to charge me when my deductible and OOP have been met? 

The medical providers work closely with Western Health Advantage in sharing this information on a daily basis to determine the correct amount of deductible to apply to each claim, if applicable.

How do I get reimbursed for overpaying my deductible and/or OOP?

Contact Member Services department and they can assist you.

Last review date: March 24, 2020

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