Employee Elect Basic PPO Plan Explained:
One of the nine available plans to small groups interested in health coverage from Anthem Blue Cross is the Employee Elect Basic PPO plan. This plan offers a lower priced alternative for your employees who may need PPO coverage, but couldn’t afford a more comprehensive package. Here’s what your employees can expect from this plan.
Annual Deductible - The annual deductible is $1250, per member. This means that once your employees reach this amount, most of their services will be covered.
Plan Maximum - This plan carries a high maximum limit of $5,000,000. Many PPO plans do not offer this high of a limit.
Out-of-Pocket Maximum - Your employees will have a maximum yearly out-of-pocket expense of $2000 under this plan. This amount is in addition to the annual deductible.
Office Visits - Office visit coverage is not offered under this plan. However, if your employees do not foresee the need for several visits, the other options of this plan make it more desirable.
Hospital Inpatient Coverage - Once your employees meet their deductible, they will need to pay for 20% of the negotiated fee, if they visit an in-network hospital. If they opt for an out-of-network hospital, they would then be required to pay for all charges, minus $650 per day, after they have met their deductible.
Hospital Outpatient Coverage - This plan requires a payment of 20% of the negotiated fee after the deductible has been met for outpatient care provided by an in-network hospital. If the care is received outside the network, this changes to 100% of the fee, minus $380 per day, after the deductible is met. Outpatient coverage is limited to radiation therapies, surgery, hemodialysis treatment, infusion therapies or medical emergencies.
Prescription Coverage - Prescriptions are not subject to the annual plan deductible and are charged in the following manner for participating pharmacies: $10 co-pay for generic prescriptions that are listed in the Anthem Blue Cross formulary, $25 co-pay for brand name drugs, if the generic is not available, $10 plus the difference in cost for brand name prescriptions when a generic is available and 30% of the negotiated fee for injectables, excluding insulin. If the pharmacy is not a Anthem Blue Cross participating pharmacy, the costs will be 50% of the negotiated fee plus 100% of any excess charges.
Healthy Check Screenings - These screenings are not subject to your employees’ annual deductible. They will be able to select from a $25 Healthy Check screening or a $75 Healthy Check screening.
Emergency Care - If your employees are admitted to the hospital after requiring emergency care, the $100 ER co-pay is waived. If they are not admitted, they will be required to supply this co-pay. For participating hospitals, employees will need to pay for 20% of the negotiated fee for services received. At non-participating hospitals, this costs moves up to 20% of the customary fee, plus 100% of any excess fees for the first 48 hours. After this point, they will then be required to pay 100% of all charges, minus $650 per day, once they have met their deductible.
Skilled Nursing Facility - If your employees’ require care in a skilled nursing facility that is a participating facility, they will be required to pay for 20% of the negotiated fee, plus 100% of any excess fees over $540, once their deductible has been met. If the nursing facility is not a participating member, the charges are 100% minus $380 per day, after the plan deductible has been met.
This should give you an idea of the general offerings for this plan. There are different exclusions that your employees will need to be aware of, and it is a good idea to have your employees discuss this plan completely with your administrator.
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