2019 Staff Medical Plan Options

Transcription

1 2019 Staff Medical Plan Options PHBP Staff Plan Options: PHBP Classic Premier PPO PHBP Classic Plus PPO PHBP California Classic HMO (CA Only) PHBP Health Savings Account (HSA) Anthem Plan Designations Anthem Classic PPO 500/25/20 Anthem Classic PPO 500/30/20 Anthem Classic HMO 10/30/250 Admit/125 OP Anthem PPO HAS 2700/20 DEDUCTIBLE In-Network Non-Network In-Network Non-Network In-Network Non-Network In-Network Non-Network Individual $500 $1,500 $500 $1,500 $0 Not Applicable $2,700 $8,100 Family $1,000 $3,000 $1,000 $3,000 $0 Not Applicable $5,400 $16,200 OUT-OF-POCKET MAX Individual OOP $2,500 $5,000 $4,000 $12,000 $2,000 Not Applicable $5,000 $15,000 Family OOP $5,000 $10,000 $8,000 $24,000 $4,000 Not Applicable $10,000 $30,000 PHYSICIAN SERVICES Office Visit Copays $25 50% coinsurance $30 copay 50% coinsurance $10 Not Covered 20% coinsurance 50% coinsurance Preventive Care $0 50% coinsurance $0 50% coinsurance $0 Not Covered $0 50% coinsurance Diagnostic Lab/X-Ray 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $0 Not Covered 20% coinsurance 50% coinsurance Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $100 copay per test Not Covered 20% coinsurance 50% coinsurance Rehabilitation/Habilitation (PT/OT/ST) 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $10 copay per visit Not Covered 20% coinsurance 50% coinsurance Chiropractic Care $20 copay per visit 50% coinsurance $30 copay per visit 50% coinsurance $10 copay per visit Not Covered 20% coinsurance 50% coinsurance Acupuncture $25 copay per visit 50% coinsurance $30 copay per visit 50% coinsurance $10 copay per visit Not Covered 20% coinsurance 50% coinsurance PRESCRIPTION DRUGS Tier 1 (Generic Formulary) $10 $ % coinsurance $5/$20 50% up to $250 $5/$20 50% up to $250 $5/$15 50% up to $250 Tier 2 (Preferred Brand Formulary) $30 $ % coinsurance $40 50% up to $250 $40 50% up to $250 $40 50% up to $250 Tier 3 (Non-Preferred Brand Formulary) $50 $ % coinsurance $65 50% up to $250 $65 50% up to $250 $60 50% up to $250 Tier 4 (Specialty Drugs) $500 Deductible 30% up to $150 50% coinsurance 30% up to $250 50% up to $250 30% up to $250 50% up to $250 30% up to $250 50% up to $250 T1: $10 T1:$12.50 T1:$12.50 T1:$12.50 Mail Order T2: $60 T2:$120 T2:$120 T2:$120 50% coinsurance 50% up to $250 50% up to $250 T3: $100 T3:$165 T3:$165 T3:$180 50% up to $250 T4: 30% up to $300 T4:30% up to $250 T4:30% up to $250 T4:30% up to $250 HOSPITAL FACILITY SERVICES Inpatient Hospital Services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $250 copay per admit Not Covered 20% coinsurance 50% coinsurance Outpatient Surgery in a Hospital 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $125 copay per admit Not Covered 20% coinsurance 50% coinsurance Ambulatory Surgical Center 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $125 copay per admit Not Covered 20% coinsurance 50% coinsurance EMERGENCY SERVICES Emergency Room $150 copay per admit $150 copay per admit $150 copay per admit $150 copay per admit then 20% coinsurance then 20% coinsurance then 20% coinsurance then 20% coinsurance $100 copay per visit Covered as In Network 20% coinsurance 20% coinsurance Emergency 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance $100 copay per trip Covered as In Network 20% coinsurance 20% coinsurance Urgent Care $25 copay per visit 50% coinsurance $30 copay per visit 50% coinsurance $10 copay per visit Covered as In Network 20% coinsurance 50% coinsurance MENTAL HEALTH/SUBSTANCE USE DISORDER Outpatient Services $20 copay per visit 50% coinsurance $30 copay per visit 50% coinsurance $10 copay per visit Not Covered 20% coinsurance 50% coinsurance Inpatient Services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $250 copay per admit Not Covered 20% coinsurance 50% coinsurance MATERNITY Prenatal and Postnatal Care $25 copay per visit 50% coinsurance $30 copay per visit 50% coinsurance $10 copay per visit Not Covered 20% coinsurance 50% coinsurance Delivery & All Inpatient Services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance Not Covered 20% coinsurance 50% coinsurance MEDICAL RATES

2 2019 Ancillary Plan Options Dental and Vision Bundle DENTAL - ANTHEM BLUE CROSS VISION - METLIFE DEDUCTIBLE In Network Non-Network DEDUCTIBLE In Network Copay Frequency Individual $50 $50 Exams $10 12 Months Family 3x Indvidual Ded 3x Indvidual Ded Frames $200 allowance 12 Months Waived Tier for Deductible Tier 1 Tier 1 TIER COPAYS FRAME ALLOWANCES Tier 1 Diagnostic & 100% 100% Single Vision $25 12 Months Tier 2 Basic Services 80% 80% Bifocal $25 12 Months Tier 3 Major Services 50% 50% Trifocal $25 12 Months Tier 4 Orthodontia 50% 50% Polycarbonate $25 12 Months Tier 1-3 Benefit Maximum $1,500 $1,500 Anti-Reflective Coating up to $41 - $85 copay 12 Months Tier 4 Benefit Maximum $1,500 $1,500 Progressive Lenses up to $55 copay (standard) 12 Months

3 Health Savings Account (HSA) Account Ownership Deposits Made By Separate Account Expenses Covered Accompanying Plan Requirements Employee/ Individual Employer, employee or both Required; IRA-type account Medical, dental, vision, prescription and some over-the-counter expenses. COBRA, retiree medical insurance premiums, LTC premiums or expense Reference: IRC 213(d) Must be covered by qualified HDHP and not covered by any plan that covers medical expenses under the deductible HDHP Minimum Deductible: 2019: $1,350 single; $2,700 family Contribution Limits 2019: $3,500 self-only; $7,000 family; Catch-up: $1,000 Portability Rollover Funds Availability Claim Adjudication Compatibility with Other Savings Accounts Employer Contributions Retirees Debit Card Usage Contributions for Medicare Participants Usage for Ineligible Expenses Distributions for Expenses Incurred After Individual is No Longer Eligible Full portability required Full rollover required As deposits are credited Not allowed; though participants must retain receipts May be paired with HRA/ FSA if limited to amounts over deductible, or to dental/ vision only; may be paired with DCAP, PRA Can be made on behalf of current employees (account extends to spouse and dependents) Can be covered Yes Contributions cannot be made once an individual has Medicare coverage Allowed. Amounts included in income; subject to 20% penalty unless after account beneficiary s death, disability or attaining age 65 Can be made

4 How does COBRA affect HSA eligibility? Can I use my HSA funds to pay for my COBRA premiums? Can I use my HSA funds while on COBRA for medical expenses? Are there any taxes involved with withdrawing money from my HSA? Can I get reimbursed for expenses from a prior year? COBRA Continuation Coverage If a member is enrolled in an HSA-qualified medical plan and is eligible for COBRA continuation, the member can remain covered on that plan. Furthermore, as long as they remain HSA-eligible, they can continue to contribute to the HSA. COBRA premiums can be paid from an HSA. Please note that generally, health insurance premiums cannot be paid from an HSA, however, exceptions are granted if the member has COBRA continuation coverage through a former employer, or they are collecting federal/state unemployment benefits. During COBRA money in an HSA can be used tax-free for eligible medical expenses for the account holder, his or her spouse, and any current tax dependents. In addition to COBRA premiums, the HSA money can be used tax-free for Medicare Part B, Part D and Medicare Advantage premiums as long as the account holder is age 65 or older. A member can withdraw HSA funds tax-free at any point for qualified medical expenses, but if it is used for non-medical expenses, taxes need to be paid on those withdrawals. Furthermore, if there is a withdrawal of money before age 65 for non-medical expenses, a 20% penalty applies. IRS-qualified medical expenses from previous years are reimbursable at anytime as long as the IRS-qualified medical expenses were incurred after the HSA was established.

5 Anthem Blue Cross Find a Provider Tool Producers Health Benefits Plan Step 1: Go to: Scroll over Individual & Family. Under Care, Click on Find a Doctor ( Step 2: There are two ways to search for a doctor. Members can enter their login information to access their personalized online profile and search for doctors on the network in which they are currently enrolled. Or prospective members or members who want to search for doctors on a network in which they are not currently covered can search as a guest. Scroll to the bottom of the page to find: Medical Dental Medical CA HMO: Blue Cross HMO (CACare) Large Group CA PPO: Blue Cross PPO (Prudent Buyer) Large Group Out of CA PPO: National PPO (BlueCard PPO) Dental Dental PPO: Dental Complete

6 Step 3: Complete the steps below to find a doctor. Use the provider finder online only or choose a format to receive the customized directory: Once you press you will get a listing of doctors. You can refine your search results after you get a listing. Important to Remember for HMO: HMO care is managed by the medical group you choose. Make sure the doctor you choose has a contract with the medical group you select. If you are trying to coordinate to have the opportunity to utilize a specific hospital, make sure that both the doctor and medical group have contracts with that hospital. However, it is up to the medical group as to which hospitals they utilize regardless of contracts.