2020 | PLAN GUIDE INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN GUIDE Serving all counties in Idaho Policy No. 18-069-01/20 18-073-01/20 18-102-01/20 18-116-01/20 18-704-01/20 18-724-01-20 18-070-01/20 18-075-01/20 18-107-01/20 18-117-01/20 18-722-01/20 18-770-01/20 18-071-01/20 18-076-01/20 18-108-01/20 18-118-01/20 18-723-01/20 18-788-01/20 Form No. 20-013 (01-20) 18-072-01/20 18-078-01/20 18-109-01/20 BLUE CROSS OF IDAHO Make the Choice that Works for You. When it comes to finding the right healthcare coverage, we know you have choices. Understanding how to make the best choice is the first step in choosing the right plan with the coverage you want and the benefits you deserve. We are here to make it easier for you so you can get on with your life with less worry, less hassle and more financial peace of mind. There’s a reason why thousands of your friends and neighbors trust Blue Cross of Idaho. We understand when to step in and help you through the health insurance process. We also know when to get out of the way and let you work with your provider to take control of your health. We understand the important questions you may have about our plans or health coverage in general. We have the tools you need to make informed decisions and get the most out of your health plan. We are Idahoans who have been helping Idahoans make the most informed healthcare decisions for over 70 years. And we’d love to serve you. 2 HEALTH PLANS | BLUE CROSS OF IDAHO Ready to find a plan that’s right for you? Let’s The following pages outline specific Blue Cross of Idaho networks and plans. Get If you need help, call your insurance agent or talk to Blue Cross of Idaho sales team today Started at 1-888-GO-CROSS (1-888-462-7677). Follow these steps to find the best plan to meet your needs and get the coverage you deserve. HERE’S YOUR CHECKLIST: Find a plan that fits your lifestyle and budget on pages 2 - 5. See if you qualify for a tax credit or cost-sharing reduction. If you qualify for a cost-sharing reduction, see pages 6 - 9. If you are a Native American or American Indian, see pages 10 and 11. Read how your plan will work, review the networks, PCPs and hospitals available where you live, pages 12 - 17. Buy your plan. Open enrollment is November 1 through December 16, 2019. BLUE CROSS OF IDAHO | HEALTH PLANS 1 KEY TERMS Affordable Care Coinsurance C Blue Cross of Idaho shares the cost of your AT IC GOLD SILVER BRONZE ASTROPH healthcare covered under your plan. For Act (ACA) Plans example, if we cover 70 percent of a doctor’s charges, you’re responsible for paying the remaining 30 percent. LEARN MORE ABOUT THE METAL LEVELS: BRONZE, Copay A set amount you pay directly to a doctor, SILVER AND GOLD hospital or pharmacy when you need a service. Depending on your plan, you might C AT IC pay a copayG OtoLD see a primary care provider SILVER BRONZE ASTROPH (PCP), have an MRI or visit the ER. If you don’t see a doctor very often, a bronze plan is a great way to save Deductible on your monthly premium. We pay The dollar amount you pay for most about 60 percent of the average healthcare you get before your insurance plan starts to pay. Some plans have one deductible medical costs.* for medical care and a separate deductible for prescriptions. CA C G S B E TA HI In-Network OLD If you see a doctor once in a while,ILVER a RONZ STROP Care you receive from a primary care provider silver plan is a good option. This is a on your plan’s list of covered doctors or care you receive from a doctor, hospital, clinic “middle-of-the-road” plan where we or pharmacy on your plan’s list of covered pay about 70 percent of the average doctors when you have a referral. medical costs.* You can find a list for your plan network at bcidaho.com/findaprovider. Out-of-Network If you go to the doctor regularly, Care you receive from a doctor, hospital or a gold plan may be right for clinic who is not on your plan’s list of covered you. You pay a higher monthly doctors or without a referral from your primary care provider. premium, but Blue Cross of Idaho pays about 80 percent of the Even if you have a referral, providers who are not on your plan’s list can also bill you average medical costs.* for whatever insurance doesn’t cover; this is * Payment percentages are based on an average called “balance billing” and is a major reason person’s healthcare expenses over a year. you should use providers in your plan’s network. Out-of-Pocket Maximum The combined maximum deductible, copay, FIND YOUR PLAN BEFORE THE and coinsurance amount you pay for covered healthcare each year. FOLLOWING BENEFIT GRIDS The following benefit grids outline common in- and Premium The amount you pay monthly for your health out-of-network services, and are not comprehensive insurance plan. lists of benefits. For more information, please visit bcidaho.com/SBC to review a Summary of Benefits and Coverage. 2 HEALTH PLANS | BLUE CROSS OF IDAHO SUPPORT FROM LOCAL NETWORKS When you choose a Blue Cross of Idaho managed care plan, you must choose a primary care provider (PCP) from your local network. Your PCP will serve as your care coordinator and provide referrals to visit specialists or other healthcare providers. BRONZE 8150 OR BRONZE 6300 OR BRONZE HSA 6000 OR BRONZE CAREPOINT 8150 BRONZE CAREPOINT 6300 BRONZE HSA CAREPOINT 6000 What You Pay What You Pay What You Pay What You Pay What You Pay What You Pay In Network Out of Network In Network Out of Network In Network Out of Network BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits $40 $40 Urgent Care Visits 60% after 60% after 20% after 60% after deductible deductible deductible deductible Specialist Visits $65 $105 (w/referral) Preferred Generic $5 after deductible* $5 after deductible* Prescriptions $15 $15 $15 $15 Non-Preferred Generic $10 after deductible $10 after deductible Prescriptions Immunizations $0 $0 $0 $0 $0 $0 Preventive Care Diabetes Education $20 $20 Outpatient Mental 60% after 60% after 60% after Health and Substance deductible deductible 20% after deductible Abuse Visits $40 $40 deductible Applied Behavior Analysis Visits1 OTHER BENEFITS YOU MIGHT NEED $350 $350 $350 $350 $350 Emergency Room Visits after deductible2 after deductible after deductible2 after deductible after deductible2 Imaging $500, then 40% $500, then 60% $250, then 20% $250, then 60% (MRIs, CT scans) after deductible after deductible after deductible after deductible Lab Work and X-rays Surgery (doctors $0 charges, anesthesia and after deductible 60% after other covered charges) deductible 40% after 60% after 20% after 60% after Having a Baby deductible deductible deductible deductible (pregnancy care, delivery and after care) Therapy Visits3 (PT, ST, and OT) WHAT YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR How much you’ll pay each year before we start paying for some services; Medical Deductible deductible is doubled for family policies, no matter how many are covered $8,150 $16,300 $6,300 $16,300 $6,000 $16,300 Prescription Deductible No separate drug deductible No separate drug deductible No separate drug deductible The percent you’ll pay for covered services; we’ll pay the other part Coinsurance 0% 60% 40% 60% 20% 60% The most you’ll pay out of pocket each year for covered care and prescriptions; Out-of-Pocket maximum is doubled for family policies, no matter how many are covered Maximum $8,150 $81,500 $8,150 $81,500 $6,850 $81,500 IF YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand $35 after deductible $35 after deductible $35 after deductible Name Prescriptions4 Non-Preferred Brand $50 after deductible $50 after deductible $50 after deductible Name Prescriptions4 Preferred 30% after deductible 30% after deductible 30% after deductible Specialty Drugs Non-Preferred 50% after deductible 50% after deductible 50% after deductible Specialty Drugs *The Bronze HSA 6000 plan includes an additional list of prescriptions with no copay. The HSA Preventive Drug List can be found online at members.bcidaho.com. See page 5 for footnote descriptions. BLUE CROSS OF IDAHO | HEALTH PLANS 3 SILVER 6000 OR SILVER 5000 OR SILVER 4000 OR SILVER CAREPOINT 6000 SILVER CAREPOINT 5000 SILVER CAREPOINT 4000 What You Pay What You Pay What You Pay What You Pay What You Pay What You Pay In Network Out of Network In Network Out of Network In Network Out of Network BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits $20 $30 $35 Urgent Care Visits 60% after 60% after 60% after deductible deductible deductible Specialist Visits $50 $60 $55 (w/referral) Preferred Generic $5 $5 $5 $5 $5 $5 Prescriptions Non-Preferred Generic Prescriptions $10 $10 $10 $10 $10 $10 Immunizations $0 $0 $0 $0 $0 $0 Preventive Care Diabetes Education $20 $20 $20 Outpatient Mental Health and Substance 60% after 60% after 60% after Abuse Visits deductible deductible deductible $20 $30 $35 Applied Behavior Analysis Visits1 OTHER BENEFITS YOU MIGHT NEED $350 after $350 after $350 after $350 after $350 after $350 after Emergency Room Visits deductible deductible2 deductible deductible2 deductible deductible2 Imaging $250, then 20% $250, then 60% $250, then 40% $250, then 60% $250, then 40% $250, then 60% (MRIs, CT scans) after deductible after deductible after deductible after deductible after deductible after deductible Lab Work and X-rays Surgery (doctors charges, anesthesia and other covered charges) 20% after 60% after 40% after 60% after 40% after 60% after Having a Baby deductible deductible deductible deductible deductible deductible (pregnancy care, delivery and after care) Therapy Visits3 (PT, ST,