If you are enrolled or considering enrolling in the High Deductible Health Plan (HDHP), the following should provide you with some helpful tips on how the plan works and should help alleviate any anxiety when using your the HDHP health coverage.
High Deductible Health Plan - Plan Features and Highlights:
The plan requires an upfront Annual Deductible of either $2,000 for individual coverage or $4,000 for family coverage (family coverage includes individual plus one or more family members). Once the annual deductible is met, most services are covered in full, except for office visits which require a $15 co-payment.
Although there is a $4,000 deductible for family coverage, there is a per member cap of $2,000. For example, if a covered member of your family meets his/her $2,000 deductible for the year, his/her deductible type services will be covered in full for the remainder of the year. Then, other covered family members are subject to meeting the remaining $2,000 deductible. Once the full $4,000 deductible is met, all deductible type services for all covered family members are covered in full.
Annual routine preventive visits and Rx co-payments are NOT part of the deductible or out-of-pocket maximum. These co-payments are always required by the member and should be paid at the time of service.
If you use out-of-network coverage, you are also subject to an Annual Out-of-Pocket Maximum of either $5,000 or $10,000 depending on coverage level. This annual maximum includes the annual deductible.
Remember, the HDHP is part of the PPO National Network which includes more than 90% of all practicing physicians and hospitals in the United States (not limited to Massachusetts like the HMO plans).
Health Reimbursement Account
A Health Reimbursement Account (HRA) is automatically provided and funded by WHOI to cover the first 50% of the annual deductible upfront. So, an employee enrolled in individual coverage is eligible to receive reimbursement for the first $1,000 spent on deductible services. For family coverage, reimbursement would be on the first $2,000 spent on deductible services. Once the HRA is exhausted, you are responsible for the remainder of the annual deductible.
NOTE: The HRA is pro-rated for any mid-year enrollments into the HDHP plan. (Example, an employee who enrolls in the HDHP in March will receive 10/12ths of the annual HRA amount)
How will I pay for my medical expenses under the HDHP?
- Effective January 1, 2011, under the Patient Protection and Affordable Care Act, annual routine preventive care services are covered in full with no office visit co-payment or deductible charges.
- For Rx prescription drugs, you will only pay the required Rx co-payment ($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:
- Pay nothing at the point of service *
- Provider will submit claim to BCBS
- BCBS will process claim and submit an EOB (Explanation of Benefits/Claims Summary) to both you and the provider listing the ‘allowable charges’ to be paid to the provider
- Provider will then bill the patient for the total ‘allowable charges’ *
- You then pay the provider directly (see additional instructions below for receiving your HRA reimbursement)
* Some providers may request to collect the $15 office visit co-payment at the point of service as part of their routine office practice procedures. If paid, please just be sure this amount is applied to and deducted from the provider bill.
How will I receive my HRA reimbursement?
- Once BCBS processes your claim, they will automatically submit a file to Health Equity
- Health Equity (our third party HRA claims administrator), will check your HRA account to verify funds are available
- If HRA funds are available, Health Equity will automatically disperse payment from the HRA account to your healthcare provider.
We understand this type of plan is new for many and will require a new way of thinking about how you use your healthcare. You are strongly encouraged to communicate with both your providers and BCBS throughout the year to ensure a smooth process and to avoid any unexpected claims issues along the way. Don’t be afraid to ask questions!
And, don't forget to sign up for the BCBS Member Self-Service for online access to view your personal claims data. The link is provided below under 'related links.'
BCBS Member Services:
Linda Snow (X 3763) firstname.lastname@example.org
Patty Mahoney (X 2602) mailto:email@example.com
Link to BCBS Member Self-Service page: