Wyandotte High School

Health Insurance Plans

Health Insurance Plans Health Insurance Plans HMO (Health Maintenance Organization)• Select a Primary Care Physician (PCP)• No Referral for Network Specialist• In-Network OnlyPPO (Preferred Provider Organization)• Freedom of Choice – You select your Primary Care Physician• In and Out of Network /National and International CoverageConsumer Driven Health Plan - • QHDHP (Qualified High Deductible Health Plan)• In and Out-of Network /National and International Coverage• Employee Owned Health Savings or Personal Care Account• HSA or PCA to Pay for Medical, Drug, Vision, & Dental

Expenses

Medical Plans Con’tMedical Plans Con’t

• HMO (Health Maintenance Organization) - a plan prepaid by an individual or by a company for its employees, that provides treatment, preventive care, and hospitalization to each participating member

• PPO (Preferred Provider Organization) -a comprehensive health plan offered to employees that allows them to choose their own physicians and hospitals within certain limits.

• CDHP (Consumer Driven Health Plan) must be tied to a tax-exempt health savings account (HSA) or health reimbursement account (HRA), in which you or your employer deposit money to use for medical expenses. The HSA is used by the employee to pay medical expenses on a pre-tax basis

Health Care Definitions

• Deductible - The amount for which the insured is liable for before an insurance company will make payment. First responsibility in a calendar year

• Coinsurance - A cost-sharing agreement between the insured and the insurer under a health policy which pays a percentage of the covered costs after the deductible has been paid. at the time the service is rendered.

• Out of pocket maximum - The most you will have to pay in a year for deductibles and coinsurance for covered benefits.

• Copay - The amount an insured person is expected to pay for a medical expense at the time of the visit. A flat fee charge regardless of services rendered (Example: $20)

• Pre-existing Condition- a health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy; also written pre-existing condition. On the PPO plan - Pre-existing Exclusion Period does not apply to children under age 19.

• Basic Coverage Limit- Lowest amount of coverage for which an insurance policy can be written, as prescribed in the insurance legislation or as set by the insurance company.

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Before We Get Started….

• Health Care ReformWhat’s covered now? And what’s covered in the future?– Dependents are covered to the end of the calendar year they turn 26

regardless of student status– 100% Coverage on Preventive Care– Network and Non-network Emergency Services paid the same– Unlimited Lifetime Maximum– On the PPO plan - Pre-existing Exclusion Period does not apply to

children under age 19– No Calendar Year Maximum on DME (Durable Medical Equipment)– Unlimited Lifetime Maximum on Organ Transplants– BlueKC.com will provide current information and Frequently Asked

Questions

Primary Care Physician (PCP)(GP, FP, IM, Ped)

$25 copay

Specialist (no referral)(Allergist, ENT, OB/Gyn)

$50 copay

Inpatient Hospital Services/Outpatient Surgery

$100 per day up to$1,000 individual / $2,000 family

MRI, MRA, CT and PET Scans – Physician’s Office, Imaging Center, Outpatient Setting

$150 copay

Urgent Care(includes CVS Minute Clinics; Walgreen’s Take-Care Centers)

$50 copay(Office Visit and Lab only)

Emergency Room Services $150 copay(Copay waived if admitted to a network hospital)

HMO

Traditional HMO Plan

Centerpoint Medical CenterChildren’s Mercy Hospitals

KU Medical CenterLee’s Summit Hospital

Menorah Medical CenterNorth Kansas City

Olathe Medical CenterOverland Park Regional

Providence Medical CenterResearch Medical Center

Shawnee Mission Medical Cente

St. Luke’s Hospitals ARE NOT in the Blue-Care network

www.BlueKC.com

Blue-Care Blue

PPOIn-Network Out-of-Network

Deductible: The portion the covered person must pay each calendar year before insurance will provide benefits.

Individual DeductibleFamily Deductible

$500$1,000

$1,000$2,000

Coinsurance: Portion of covered charges paid by BCBSKC after you satisfy your deductible.

Coinsurance Member pays: 10%BCBSKC pays: 90%

Member pays: 20%BCBSKC pays: 80%

Out-of-Pocket Maximum In-Network Out-of-Network

Individual MaximumFamily Maximum

$2,500$5,000

$5,000$10,000

Out-of Pocket Maximum: Total of deductible and coinsurance that members pay each calendar year toward covered services before insurance pays 100%.

Preferred-Care Blue (PPO)53 Metro Area Hospitals Including:

Centerpoint Medical CenterChildren’s MercyKU HospitalLee’s Summit HospitalMenorah Medical CenterNorth Kansas City Hospital

Olathe Medical CenterOverland Park RegionalResearch HospitalsSaint Luke’s HospitalsShawnee Mission Medical Center

Liberty, St. Joseph, St. Mary’s and Truman Hospitals are not in the Preferred-Care Blue Network

Urgent Care• Receive care for non-life threatening

conditions.• You are responsible for the copay

when using Urgent Care Facilities• Use Walgreen Take-Care Centers or

CVS Minute Clinics• If you are outside of the service

area, contact your Primary Care Provider prior to treatment. – (HMO Plan Only)

Emergency Care• Go to the nearest Emergency

Room or call “911”.• Receive treatment and pay the

copay. • Contact your PCP – within 48

hours (or as soon as reasonably possible) after you receive medical attention.

Urgent Care and Emergency Care

Travel with Your PPO Health Plans

As a Member, you can take your healthcare benefits with you across the country and around

the world.

The PPO Program gives you access to over 6,000 hospitals and 800,000 physicians around the

country, giving you the peace of mind that you can take charge of your health, wherever you are.

Visit our website at www.bluekc.com click Find BlueKC Doctors, Hospitals and Pharmacies, click BlueCard Provider Directory, click Continue. Login using

the ID number on the front of your BCBSKC ID Card.

or call (800) 810-BLUE (2583) to receive a complete list of network hospitals and physicians.

Prescription Drugs

Prescription Drugs[Not Creditable

To Medicare Part D]

Costco’s, CVS, Hen House, Hy-Vee, K-Mart, Price Chopper, Sam’s Club, Sun Fresh, Target, Walgreen’s, Wal-Mart

Retail (34 day supply)

:$10 copay for Tier 1$30 copay for Tier 2$50 copay for Tier 3

Tier 1 – GenericsTier 2 – Name Brand

Tier 3 – New on Market

Routine Preventive CareRoutine Preventive Care

Covered at 100%

Physician ExaminationsCBC Metabolic Screening

UrinalysisGlucose Screening

Thyroid Stimulating Hormone ScreeningLipid Cholesterol Panel

HIV ScreeningHPV Screening

Chest X-rayEKG

Covered at 100%

PSA Tests Pelvic Exams and Pap Smears

MammogramsChildhood Immunizations

Lead Testing Colorectal Cancer Exams

Newborn Hearing Screening

What Can I Do?

Annual Preventive Exams

Always Use Network Providers

Use Urgent Care Centers/Take-Care Facilities

Ask your doctor for prescription drug samples

Take Medication as Prescribed by Physician or according to Manufacturers Guidelines

Consider Your Overall Health ..diet, exercise,

personal habits…

Ask your Doctor or Pharmacist if there is a generic substitute for a name brand prescription

Not sure? Ask Questions!

Traveling? Do your homework. Find a network provider in that area.

Thank you!Thank you!

Questions & Answers