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Classic HMO Edges Towards HMO 100% |
While looking for predictable health care costs, an HMO from Blue Cross of California has the most consistent coverage and service levels. However, with four HMO plans to choose from there are some variations.
Negotiations with health care providers for both the Classic HMO and the HMO 100 percent plans, are conducted to reach the best prices on all services. The negotiated price is what the network providers will be their charge for negotiated services for enrolled plan members and they will accept that as payment in full, plus any copay that may be required.
Neither the Classic HMO nor the HMO 100 percent require an annual deductible for any of the family enrolled plan members. There is a $1,750 maximum annual out-of-pocket charge per plan members, with a $3,500 aggregate for all family enrolled plan members. This means that if one or more members of the same plan pay a combined $3,500 the annual maximum out-of-pocket expense is satisfied. This is the same for both the Classic HMO and the HMO 100 percent plans.
With the HMO 100 percent plan there is $10 copay required for network doctor’s visits, and there is no coverage for doctors outside the network. With the Classic HMO plan the copay is $20 for network doctor visits and no coverage for out of the network visits.
There is no charge for professional services performed by offices in the network for diagnostic services, E-ray and maternity except for the $10 office copay for HMO 100 percent plan members and the $20 copay for Classic HMO plan members. There is no coverage for out of network service providers in either plan.
Hospital care is available through in network facilities only and with the HMO 100 percent plan there will be no charge. Persons enrolled in the Classic HMO will be charged a $250 copay per admission and treatment as an outpatient will require a 20 percent copay.
Prescription drugs are not subject to the annual medical deductible, but there is a $150 annual prescription deductible for name brand drugs for both plans. Both plans also feature a $10 copay for generic drugs. The HMO 100 percent plan requires a $20 copay for name brand drugs, once the annual $150 deductible has been met and the Classic HMO has a $25 copay for name brands once the $150 deductible has been met. The copay amounts apply for every 30-day supply or up to a 60-day supply if obtained through mail order.
In both the Classic HMO and the HMO 100 percent, if an enrolled plan member chooses a name brand drug when there is a generic drug available, the member will be responsible for the generic copay plus the difference in costs between the generic price and the name brand price, even if the doctor wrote the prescription restricting it to dispense as written or do not substitute. The amount paid this way does not contribute to the annual name brand prescription deductible.
For self-injected drugs, the cost will be 30 percent of the negotiated price, except for insulin, and is subject to the brand name drug deductible, if applicable. For both plans there is and unlimited lifetime amount for in network covered charges.
Learn more at: www.baahealth.com
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