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Low Deductible Health Plan (LDHP)

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Advantage Blue

The Low Deductible Health Plan (LDHP) is a new medical plan for 2014.  The following will provide you with a summary of the plan along with some helpful tips on how the plan works.

Plan Features and Highlights
  • BCBS Plan Name: Advantage Blue
  • New plan for 2014
  • WHOI pays 60% of the premium, employee pays 40%
  • Annual Deductible: $500 for individual coverage, $1,000 for family coverage*
  • Uses BCBS' national PPO network
  • In-network coverage only (except for emergency services)
  • No Primary Care Physician required
  • No referrals to Specialists required
  • Employees can participate in traditional Healthcare Flexible Spending Account (Health FSA)

* family coverage = employee + spouse, employee + child(ren), and employee + family

Annual Deductible
The plan requires an upfront annual deductible of $500 for individual coverage and $1,000 for family coverage.  Once the annual deductible is met, all deductible type services are covered in full for the remainder of the year.

Although there is a $1,000 annual family deductible, there is a per member cap of $500.  For example, if a covered member of your family meets his/her $500 deductible (individual cap), then his/her deductible type services are covered in full for the remainder of the year.  Then, other covered family members are subject to meeting the remaining $500 deductible.

Services subject to the Annual Deductible  
Only in-patient and out-patient hospital services are subject to the deductible under this plan.  Annual routine preventive visits are covered in full and are not subject to the deductible. Office visits, ER visits, and Rx prescriptions are NOT subject to the deductible under this plan and require only a co-payment.

In-Network
The LDHP plan is part of BCBS of Massachusetts national PPO provider network which includes more than 90% of all practicing physicians and hospitals across the United States (not limited to Massachusetts or New England).  To find a provider in the PPO network, visit the BCBS website at www.bluecrossma.com/findadoctor and select the 'Blue Care Elect (PPO/EPO)' network.  NOTE:  this plan covers in-network benefits only with the exception of emergency services.



How will I pay my medical expenses under the LDHP plan?

Annual routine preventive services are covered in full with no office visit co-payment or deductible charges.

Rx prescription drugs require a co-payment only and are not subject to the deductible.  Co-payments are based on the drug tier level (e.g., $15/$30/$50)

For services that are subject to the deductible, you should not pay anything at the point of service and follow these instructions:

At the Doctor's Office:
  • Go to the doctor and show your BCBS ID card
  • For services not subject to the deductible, pay your office visit co-payment using your Health FSA debit card or pay out-of-pocket if you don't have an FSA
  • For services subject to the deductible, do not pay anything to the doctor at the point of service - the doctor will submit the claim to BCBS
  • BCBS processes the claims and determines the allowable/contracted charges
  • BCBS sends a claims summary to the provider for appropriate billing and to the patient for their records
  • Provider bills patient based on the BCBS allowable charges
  • Member pays the bill out-of-pocket or with Health FSA debit card, if participating and funds are available

At the Pharmacy with or without a Health FSA:

  • Go to pharmacy - show your BCBS ID card
  • Pharmacy applies discount
  • Pharmacy processes claim and determines your member cost share
  • Member pays pharmacy out-of-pocket or with Health FSA debit card, if participating and funds are available


Last updated: December 4, 2013
 


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