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Qualifying Events

Qualifying Events

The completion of specific Qualifying Events (QE) determines your plan level for the following year.

Qualifying Events (QE) Deadlines:

  • Lab Work: June 30, 2021
  • All other Qualifying Events: August 31, 2021

Who Needs to Qualify For Plan Year 2022?

What's New This Year:

  • The Wellness Exam Form no longer requires a physician’s signature. However, the forms are required and are subject to audit. If an audit reveals information to be inaccurate, your plan level may be downgraded.
  • Members with diabetes no longer have a separate QE form - the questions have been included in the regular QE Wellness Exam Forms. Members with A1C of 9.0 still have a separate log form that will need to be submitted to Florey Miller.
  • Nicotine-Exposed members no longer need to complete additional Qualifying Events. Those who quit and wish to upgrade to the Ultimate Plan Level must still complete the early upgrade process.

ULTIMATE Plan Level

BEST Plan Level

BETTER Plan Level

BASIC Plan Level

  • No qualifying events are required

Children age 18 & under on January 1, 2021

Children complete Qualifying Events for the Ultimate Plan every year. Children are only eligible for the Ultimate or Better Plan Levels.*

*No Child Qualifying Events are required for the Better Plan.

Plan Levels

All 4 plan levels have the same premium, prescription and LAMP benefits. The only difference among the 4 plan levels is level of reimbursement (deductible, coinsurance, out of pocket costs, etc.). 

(Children are only eligible for the Ultimate or Better Plan Levels. No Child Qualifying Events are required for the Better Plan.)

Ultimate Plan
  • Must be non-nicotine exposed for this plan level
  • Highest Level of Reimbursement
  • $0 deductible; no co-insurance
Best Plan
  • For nicotine-exposed members
  • Middle to Highest Level of Reimbursement
  • $250 deductible; 20% co-insurance
Better Plan
  • Middle Level of Reimbursement
  • $500 deductible and 25% co-insurance applies
Basic Plan
  • Lowest Level of Reimbursement
  • $1000 deductible and 50% co-insurance applies
  • No QE requirements

WHY YOUR PLAN LEVEL MATTERS

If you’re relatively healthy and only see your doctor for wellness exams and maybe one sick visit a year, you may think it’s not worth your time to complete annual qualifying events. But consider this: according to the CDC, more than 20% of American’s visit the emergency room each year. If you have an emergency, how much would you expect to pay? Consider John...

John is healthy. He is at a healthy weight, exercises several times a week, and doesn’t smoke. One day, John finds himself in the hospital undergoing an emergency appendectomy which costs, on average, $33,000. John didn’t complete any qualifying events, which means he is in the basic plan level. After the surgery, John owes:

Deductible: $2,000 (Physician deductible + Hospital deductible)

50% Coinsurance max: $8,000 (Physician and Hospital Charges)

Total Due: $10,000 (which is the annual out of pocket maximum)

If John was in the Ultimate Plan Level, he would have $0 deductible, 0% coinsurance, and $0 due.