Medical
How the Plan works
The medical plan is a Preferred Provider Organization (PPO) plan. You can receive care from in-network or out-of-network providers. When you use in-network providers, you‘ll pay less for care. That’s because in-network providers discount their fees. See the example below.
- The Plan’s provider network is administered by Blue Cross Blue Shield BlueCard PPO (BCBS).
- Free in-network preventive care. This includes services like routine health screenings, immunizations, and routine annual exams.
- Once you meet the annual deductible, the Plan pays 100% of most in-network covered services, as shown in the chart below. In-network providers have agreed to accept the contracted BCBS rate as the total covered amount for services. You can’t be balance billed—that is, billed for any difference between the providers’ full charges and the lower, contracted rates.
Highlights
| Plan Feature | In-Network (and Out-of-Area) | Out-of-Network |
|---|---|---|
| Annual deductible (the amount you pay each Plan year before the plan starts paying benefits) | $300 per person / $600 family | $300 per person / $600 family |
| Annual out-of-pocket maximum (the most you pay for care in a Plan year) | $300 per person / $600 family | $1,500 per person / $3,000 family |
| Service | What You Pay for In-Network Care (based on BCBS contracted rate) | What You Pay for Out-of-Network Care (based on the usual, customary, and reasonable [UCR] rate*) |
|---|---|---|
| Preventive care visit | $0 (no deductible) | 25% of UCR (after deductible)** |
| Office visit | $0 (after deductible) | 25% of UCR (after deductible)** |
| Urgent care visit | $0 (after deductible) | 25% of UCR (after deductible)** |
| Diagnostic lab and X-rays | $0 (after deductible) | 25% of UCR (after deductible)** |
| Emergency room | $50 copay $0 (after deductible) | $50 copay 100% (after deductible)** |
| Inpatient hospital stay | $0 (after deductible) | 25% of UCR (after deductible)** |
| Outpatient surgery | $0 (after deductible) | 25% of UCR (after deductible)** |
* The UCR rate is the amount paid for a medical service in a geographic area based on the amount providers in that area usually charge for the same or similar medical service. You also pay 100% of any amount over UCR that an out-of-network provider charges.
** Plus 100% of amount over UCR
Example of how the Plan pays benefits
| Situation | In-Network Care | Out-of-Network Care |
|---|---|---|
| Doctor’s office visit | $150 (contracted rate) | $250 |
| UCR rate | N/A | $200 |
| Amount Plan will cover | 100% of contracted rate Plan pays $150 | 75% of UCR: 75% x $200 = Plan pays $150 |
| Amount you must pay | You pay $0 | 25% of UCR: 25% x $200 = $50 Plus charge in excess of UCR: $50 Total you pay: $100 |
What you need to do
- Use Blue Cross Blue Shield BlueCard PPO network providers whenever you can.
- Visit bcbs.com or call 800-810-2583 to find network providers.
Certain kinds of care require precertification. You must call KEPRO at 800-634-4832 for precertification before the plan will pay benefits for:
- All surgeries—inpatient, outpatient, or at a surgical center
- All non-emergency hospital admissions
- All emergency hospital admissions (within 48 hours of admission)
- Pain management and home health care services
- Inpatient and outpatient mental health care and substance abuse treatment
- Genetic testing
