What You Need to Know

Your medical coverage options are designed to protect your and your family’s health, as well as your finances. All medical plans cover the same expenses, but depending on the plan you elect, you’ll pay different amounts in per-paycheck deductions and out of pocket when you need care.

Your Medical Coverage Options

As a benefits-eligible employee, you have a choice of four medical plans:

  • Anthem BCBS Consumer-Directed Health Plan (CDHP) with Health Savings Account (HSA)
  • Anthem BCBS Exclusive Provider Organization (EPO)
  • Anthem BCBS Preferred Provider Organization (PPO)
  • Kaiser Health Maintenance Organization (HMO)

Preventive Care

Regular check-ins with your doctor make it easier to catch health concerns before they become real problems—saving you potential time, money, and pain in the future. All medical plans offer free in-network preventive care for you and your covered dependents, including routine physical exams, immunizations, mammograms, and more. Note: You pay coinsurance, after meeting the deductible, for out-of-network preventative services.

Your in-network preventive care visit is 100% covered by the plan. Check with your physician that your visit will be coded as preventive; otherwise, you may end up with a bill (e.g., if your visit is coded as diagnostic). If you are charged for preventive services, contact Anthem BCBS or Kaiser for assistance.

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Choosing a Medical Plan

Your medical plan election is an important decision. It’s in your best interest to carefully consider all the plans available to you and choose the one best suited to your unique situation. For example, if saving money for retiree health coverage is important to you, you should look closely at a medical plan with a Health Savings Account (HSA).

Here’s how the Anthem plans compare.

Provision Anthem CDHP with HSA Anthem EPO Anthem PPO
Out-of-network coverage? Yes No Yes
In-network preventive care covered at 100%? Yes Yes Yes
True family deductible and out-of-pocket maximum? Yes No No
Combined medical & prescription drug deductible and out-of-pocket maximum? Yes Yes Yes
Health Savings Account (HSA)? Yes No No
Health Care Flexible Savings Account (FSA)? No Yes Yes

Looking for more detail? Here’s a brief overview of each plan.

Anthem BCBS CDHP with Health Savings Account (HSA)

If you make smart health care decisions—you can save money with this plan!

  • You have the flexibility to visit both in-network and out-of-network providers, but using in-network providers will save you money.
  • Your annual deductibles and out-of-pocket maximums are higher than most other plans, but you will pay less in per-paycheck deductions than the other Anthem BCBS plans.
  • You have access to a tax-advantaged Health Savings Account (HSA) for eligible health care expenses, like the annual deductible or coinsurance. Or keep your money in the account and use it as a savings tool for your retiree health care needs.

Anthem BCBS EPO

  • You can use in-network providers only but you benefit from Anthem’s discounted pre-negotiated rates. The plan will not pay for out-of-network care, except in a true emergency.
  • There are no claim forms for you to submit with the EPO and you cannot be balanced billed.
  • You have no annual deductible—the plan starts paying benefits right away. The per-paycheck costs are lower and your out-of-pocket expenses may be less than the Anthem PPO when you receive covered services.

Anthem BCBS PPO

  • You have the flexibility to visit both in-network and out-of-network providers, but using in-network providers will save you money.
  • If you want to see out-of-network providers, you’ll generally have a lower out-of-network deductible and out-of-network out-of-pocket maximum compared to other plans. However, you’ll pay the highest per-paycheck deductions for this plan.

Kaiser Health Maintenance Organization (HMO)

  • You can enroll in this plan only if you live in California.
  • You can use in-network providers only. The plan will not pay for out-of-network care, except in a true emergency.
  • There are no deductibles to meet before the plan starts paying benefits.
  • You must select an in-network Primary Care Physician (PCP)—a doctor who will coordinate all of your medical care and provide referrals to specialists.

Key Coverage Details

Take some time to understand the following important health terms and how they work under each medical plan. You can find more detail about how each plan covers specific expenses in the medical plan comparison chart.

Annual deductible

Your annual deductible is the amount you must pay out of pocket before the plan begins to pay benefits. Here’s what you’ll pay depending on the plan you choose:

In-Network
Medical Plan Employee Employee + 1 Dependent Employee + 2 or More Dependents
Anthem BCBS CDHP $1,500 $3,000 $3,000
Anthem BCBS EPO None None None
Anthem BCBS PPO $250 $750 $750
Kaiser HMO None None None
Out-of-Network
Medical Plan Employee Employee + 1 Dependent Employee + 2 or More Dependents
Anthem BCBS CDHP $3,000 $6,000 $6,000
Anthem BCBS EPO N/A N/A N/A
Anthem BCBS PPO $250 $750 $750
Kaiser HMO N/A N/A N/A

For the Anthem BCBS EPO and PPO: Once you or a family member meets the individual annual deductible, the plan begins to pay benefits for that individual only. The plan does not pay benefits for any covered family members who have not yet met their individual deductibles.

For the Anthem BCBS CDHP: Under the CDHP, medical expenses and prescription drug expenses apply toward a combined deductible. If you have employee only coverage, once you have met the individual annual deductible, the plan begins to pay benefits for you. If you have family coverage, once you or a family member meets the family annual deductible (either by yourself or through your combined families expenses), the deductible is satisfied for all covered family members.

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Coinsurance

Once you meet your annual deductible, you and the plan begin to share the cost of coverage through coinsurance. Your coinsurance amount is the percentage of each eligible service for which you are financially responsible. Here’s what you’ll pay depending on the plan you choose:

Medical Plan In-Network Out-of-Network
Anthem BCBS CDHP 20% 40%
Anthem BCBS EPO N/A N/A
Anthem BCBS PPO 10% 30%
Kaiser HMO N/A N/A

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Co-pay

Under certain plans, you pay a flat dollar amount for some of your care—generally urgent care and emergency room visits—even if you haven’t yet met your annual deductible. Here’s what you’ll pay depending on the plan you choose:

In-Network
Medical Plan Doctor's Office Urgent Care Emergency Room*
Anthem BCBS CDHP Coinsurance Coinsurance Coinsurance
Anthem BCBS EPO $15 $15 $100
Anthem BCBS PPO $10 $10 $100 + 10% coinsurance
Kaiser HMO $10 $10 $35
Out-of-Network
Medical Plan Doctor's Office Urgent Care Emergency Room*
Anthem BCBS CDHP Coinsurance Coinsurance Coinsurance
Anthem BCBS EPO N/A N/A N/A
Anthem BCBS PPO Coinsurance Coinsurance $100 + 10% coinsurance
Kaiser HMO N/A N/A N/A
* Co-pay waived if admitted.

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Annual out-of-pocket maximum

You and the plan share in the cost of your covered expenses through coinsurance and copays (if applicable) until you reach the annual out-of-pocket maximum. Then, the plan pays 100% of covered expenses for the rest of the year. Here’s the maximum amount you’ll pay depending on the plan you choose:

In-Network
Medical Plan Employee Employee + 1 Dependent Employee + 2 or More Dependents
Anthem BCBS CDHP $3,000 $6,000 $6,000
Anthem BCBS EPO $1,500 $3,000 $3,000
Anthem BCBS PPO $2,500 $5,000 $5,000
Kaiser HMO $1,500 $3,000 $3,000
Out-of-Network
Medical Plan Employee Employee + 1 Dependent Employee + 2 or More Dependents
Anthem BCBS CDHP $6,000 $12,000 $12,000
Anthem BCBS EPO N/A N/A N/A
Anthem BCBS PPO $4,500 $9,000 $9,000
Kaiser HMO N/A N/A N/A

Note: You’ll continue to pay anything over the maximum allowable amount for out-of-network care, if applicable.

For the Anthem BCBS EPO and PPO: Once you or a family member meets your individual out-of-pocket maximum, the plan pays 100% of covered expenses for that individual only. The plan does not pay 100% of covered expenses for any family members who have not yet met their individual out-of-pocket maximums.

For the Anthem BCBS CDHP: Medical and prescription drug expenses apply toward a combined out-of-pocket maximum. If you have employee only coverage, once you have met the individual out-of-pocket maximum, the plan begins to pay 100% of covered expenses. If you have family coverage, once you or a family member meets the family out-of-pocket maximum (either by yourself or through your combined families expenses), the out-of-pocket maximum is satisfied for all covered family members.

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You must pre-certify certain expenses through the Anthem Medical Management program, including inpatient hospital care, home health care, and skilled nursing facilities. If you are seeking treatment through an in-network provider, your physician will pre-certify your care for you.

You pay for your medical coverage each pay period through convenient paycheck deductions. The amount you pay is based on the plan you choose and the level of coverage you select (i.e., employee, employee + 1 dependent, employee + 2 or more dependents).

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In-Network vs. Out-of-Network Coverage

It’s important that you use network providers whenever possible:

  • You save money because in-network providers have agreed to provide services at discounted rates, and the plans provide better coverage for in-network services.
  • You’ll generally pay lower coinsurance and have a lower annual deductible and out-of-pocket maximum when you stay in-network.
  • You never have to file claims for in-network services. Generally, when you go out-of-network, you must pay the full cost out of pocket, file a claim, and then wait for reimbursement. Plus, you may be subject to balance billing, which can cost you thousands of dollars more out of pocket.
  • Certain plans—the Anthem BCBS EPO and the Kaiser HMO—do not cover any out-of-network expenses, except in a true emergency.

Understanding balance billing

If your out-of-network provider charges above the maximum allowable amount—what Anthem BCBS has determined to be the usual cost of a health care service—you will be required to pay the applicable annual deductible or coinsurance PLUS any charges above the maximum allowable amount.

When you’re charged an amount above the maximum allowable amount, it is called balance billing. With in-network providers you’ll never be balance billed because they are obligated to charge you the maximum allowable amount or less. Out-of-network providers can charge any amount they want–often thousands of dollars more! Since the plan will only cover up to the maximum allowable amount, anything you’re charged over that amount must be paid completely by you.

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Finding an in-network provider

In-network providers can change, so it’s a good idea to check if your provider is in-network BEFORE you receive care.

Anthem BCBS providers

  • Visit the Anthem website.
  • Choose “National PPO (BlueCard PPO)” under “Select a plan/network.”
  • Search by type of care and location.

All of the Anthem plan options use the same network of providers.

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Kaiser HMO providers

  • Visit the Kaiser website.
  • Search by doctors, location, or specialty.

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LiveHealth Online

When you enroll in an Anthem BCBS plan, you have access to LiveHealth Online®. LiveHealth Online offers 24/7 access to U.S.-based, board-certified doctors on your smartphone, tablet, or computer. Use LiveHealth Online when you have a minor, non-emergency medical issue that otherwise might require a visit to your regular doctor, an urgent care center, or an emergency room—things like ear infections, sore throats, and minor injuries. The average wait time is less than 10 minutes.

Here’s how much you’ll pay for your virtual visit:

Medical Plan Coverage
Anthem BCBS CDHP 20%, after the deductible
Anthem BCBS EPO $10
Anthem BCBS PPO $10
Kaiser HMO Limited Benefits
Most LiveHealth Online visits cost $59 prior to meeting your deductible.
 

To get started, visit the LiveHealth Online website or download the mobile app.

NOTE: You should only use LiveHealth Online for non-emergency medical situations. Always call 911 in case of emergency.

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Visit with a Kaiser physician through secure video chat!

If you enroll in the Kaiser HMO, you can schedule a video visit with an in-network provider to discuss your non-emergency medical concern. It costs the same as a doctor’s office visit.

Schedule an appointment

Save Money in a Pinch: Know Where to Go

When you have an urgent medical need, or your regular doctor isn’t available and you need to see someone in person, knowing where to go for care can save you a lot of time and money. Making unnecessary trips to the emergency room can be costly, so consider these options before you make your decision.

Emergency room

Average wait time: 3+ hours

Average cost per visit§: $1,354

What you pay (in-network):

  • Anthem CDHP: 20% coinsurance, after deductible
  • Anthem EPO Plan: $100 co-pay
  • Anthem PPO Plan: $100 co-pay, plus 10% coinsurance
  • Kaiser HMO Plan: $35 co-pay

Why visit? For emergency situations, such as:

  • Wheezing or difficulty breathing
  • Chest pain
  • Open wound fractures
  • Fainting or dizziness
  • Sudden numbness or weakness
  • Bleeding that cannot be stopped
  • Changes in mental status
  • Head injury
Co-pay waived if admitted.
§ This is the average cost before your plan pays benefits. What you pay depends on the medical plan you’re enrolled in and if you’ve met your deductible. Sources: Merritt Hawkins and CVS.

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Urgent care center

Average wait time: 30 minutes

Average cost per visit§: $150

What you pay (in-network):

  • Anthem CDHP: 20% coinsurance, after deductible
  • Anthem EPO Plan: $15 co-pay
  • Anthem PPO Plan: $10 co-pay
  • Kaiser HMO Plan: $10 co-pay

Why visit? For urgent medical issues that may arise but don’t require a trip to the emergency room, such as:

  • Most fractures, cuts and burns
  • Ear infections
  • Colds and other respiratory problems
  • Sprains and strains
  • Abdominal pain
  • Vomiting and diarrhea
  • Back pain
§ This is the average cost before your plan pays benefits. What you pay depends on the medical plan you’re enrolled in and if you’ve met your deductible. Sources: Merritt Hawkins and CVS.

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Convenience care clinic

Average wait time: 10 minutes

Average cost per visit§: $120

What you pay (in-network):

  • Anthem CDHP: 20% coinsurance, after deductible
  • Anthem EPO Plan: $15 co-pay
  • Anthem PPO Plan: $10 co-pay
  • Kaiser HMO Plan: N/A

Why visit? Non-urgent medical needs, such as:

  • Diagnostic lab tests
  • General health screenings and routine physicals
  • Minor wound treatment and repairs
  • Minor illnesses
  • Preventive care and some immunizations
  • Blood pressure checks
§ This is the average cost before your plan pays benefits. What you pay depends on the medical plan you’re enrolled in and if you’ve met your deductible. Sources: Merritt Hawkins and CVS.

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