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Medical Plan Choices
Choices
HM Clause understands that each individual has different needs for themselves and their families. For this reason, we offer a range of medical plan options from which to choose for our Regular Full Time Employees. The plans vary in style, range of flexibility and freedom, and price.
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HIGH DEDUCTIBLE HEALTH PLAN
This is a High Deductible Health Plan (HDHP) offered by HM.Clause that is designed to work alongside a special Health Care Savings Account (HSA). The HDHP works much like the PPO plan, in that members have the choice of using in-network PPO providers or providers not contracted with the health plan. However, there is no first dollar coverage on a HDHP. The member must first satisfy their deductible.
Consumerism
The intent of the HDHP is to allow the member to see and pay for all claims that are incurred, prior to the deductible.Once the deductible is satisfied, the plan performs much like our traditional PPO plan.
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Freedom of Choice
A PPO plan is a program that allows considerable range of freedom. You may make any number of elections as to how and where you receive care. The out-of-pocket expense for the PPO program is best managed by always first seeking care from a contracted PPO preferred provider.
Brief Benefit Description
The HDHP has an in-network $1,650 deductible for individuals and $3,300 for families (out of network deductibles are $3,000/individual and $6,000 for families). All expenses incurred before the deductible are bore by the insured.
After the deductible, the Plan pays 80% of the negotiated fees for a PPO preferred provider, and 60% of negotiated fees for a non-contracted provider. Preferred providers accept Anthem’s allowable amount as full payment for covered services.
Non-preferred providers can charge more than these amounts. When you use non-preferred providers, you must pay the applicable copayment plus any amount that exceeds Anthem’s allowable amount. Click on the Benefit Summary below for specific details of this plan.
Click Here for HSA Summary of Benefits and Coverage
Click Here for HSA Plan Detail
Description Title
Invest in your health, tax-free
A Health Savings Account (HSA) is like an IRA for your healthcare that empowers you to prepare for and manage healthcare costs — both today and tomorrow. The account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.
Usage
Your HSA can be used to pay for all eligible expenses (typically, prescribed medical or health-related services). Examples of eligible expenses include medical deductibles, copayments, coinsurance, prescription eye care, and dental care expenses.
Tax Benefit
Participants deposit money into an HSA on a pre-tax basis. Meaning, they won't pay regular federal income tax on the HSA deposit. Additionally, most states will also honor pre-tax deposits into the HSA (California is a state that does not honor HSA deposits). HSA funds spent on eligible expenses are not taxed.
Limits
In 2024, the IRS will allow up to $4,150 for individuals, and $8,300 for families, to be deposited into the HSA account.
Use it or Keep it
Unlike the Flexible Spending Account (FSA), unspent HSA funds are allowed to roll over into the next plan year.
Rules
To participate in the HDHP, the following rules apply:
• You may not participate in any other health plan
• You cannot also participate in the Flexible Spending Account in a year you are depositing into the HSA; nor can your spouse
• You may not be covered by Medicare
• You cannot be claimed as a dependent on anyone else's tax return
Please consult with a tax professional to learn all aspects of participating and using an HSA.
PREFERRED PROVIDER ORGANIZATION (PPO)
PREFERRED PROVIDER ORGANIZATION (PPO)
PPO
We offer two Preferred Provider Organization (PPO) plans through Anthem Blue Cross for all employees across the country. The PPO plans allow you the opportunity to choose from either a participating provider or to use a provider or hospital that is not contracted with Blue Shield. The network of available providers is extensive. The best means of locating a preferred provider in your area is by using the online provider directory.
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Freedom of Choice
A PPO plan is a program that allows considerable range of freedom. You may make any number of elections as to how and where you receive care. The out-of-pocket expense for the PPO program is best managed by always first seeking care from a contracted PPO preferred provider.
Brief Benefit Description
You have two PPO plan options to choose from.
The Standard PPO plan includes a $20 co-payment for outpatient office-visits. There is a $250/$500 individual/family calendar-year deductible plan or a $500/$1,000 individual/family calendar-year deductible plan. The Plan pays 90% of the negotiated fees for a PPO preferred provider, and 70% of negotiated fees for a non-contracted provider.
Click Here for Summary of Benefits and Coverage
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The Choice PPO plan includes a $30 co-payment for outpatient office-visits. There is a $1,500/$3,000 individual/family calendar-year deductible plan or a $3,000/$6,000 individual/family calendar-year deductible plan. The Plan pays 80% of the negotiated fees for a PPO preferred provider, and 60% of negotiated fees for a non-contracted provider.
Click Here for Summary of Benefits and Coverage
Click Here for Plan Details
Preferred providers accept Anthem’s allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. When you use non-preferred providers, you must pay the applicable copayment plus any amount that exceeds Anthem’s allowable amount. Click on the Benefit Summary below for specific details of this plan.
Exclusive Provider Organization
Exclusive Provider Organization
HM.Clause offers a single Exclusive Provider Organization (EPO) plan through Anthem for employees located in California. With an EPO plan, you’re free to choose your doctor without referrals. However, your benefit coverage is limited to only within the PPO network. If you seek care from a provider outside of the EPO network, you may be responsible for the full cost of the services and your services won’t be covered.
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Limited Freedom of Choice
An EPO plan is a program that allows a limited range of freedom. You may make any number of elections as to how and where you receive care. The limitation to the EPO plan is that you must seek care from a contracted PPO preferred provider, and you cannot receive care from a provider that is out-of-network.
Click Here for Summary of Benefits and Coverage
Click Here for Plan Details
Brief Benefit Description
The EPO plan includes a $20 co-payment for outpatient office-visits. There is a $250/$500 individual/family calendar-year deductible. The Plan offers copays when seeking services through a PPO preferred provider. Click on the Benefit Summary below for specific details of this plan.
Prescription and Telemedicine
Telemedicine Online gives you 24/7/365 access to U.S. board certified doctors through the convenience of phone, video, or mobile app visits. Click here for more details.
The prescription program is incorporated with the medical plan. Depending on the selected Anthem plan, the copays varies for Generic, Preferred Brand, Non-Preferred Brand, and Specialty prescriptions. For all plans, maximum supply for retail pharmacy is 30 days and maximum supply for mail order is 90 days.
Providers
Pharmacy retail RX: Navitus, www.navitus.com, 844-268-9789,
Click here for Member Portal Registration Guide
Click here for app information.
Click here on how to compare prescription cost.
Click here for the Navitus Mobile Feature Guide
Pharmacy mail order: Birdi, www.birdirx.com, 888-240-2211
Pharmacy Specialty RX: Lumicera, www.lumicera.com. 855-847-3553
Brief Benefit Description
Anthem Standard PPO
(cost per prescription for retail | mail order)
Generic: $15 | $30
Preferred Brand: $30 | $60
Non-Preferred Brand: $55 | $110
Specialty: 20% up to $90 per prescription | not covered
Anthem Choice PPO
(cost per prescription for retail | mail order)
Generic: $20 | $40
Preferred Brand: $35 | $70
Non-Preferred Brand: $60 | $120
Specialty: 20% up to $90 per prescription | not covered
Anthem EPO (California Only)
(cost per prescription for retail | mail order)
Generic: $10 | $20
Preferred Brand: $25 | $50
Non-Preferred Brand: $50 | $100
Specialty: 20% up to $90 per prescription | not covered
Anthem HSA
(cost per prescription for retail | mail order)
Generic: $20 | $40
Preferred Brand: $35 | $70
Non-Preferred Brand: $60 | $120
Specialty: 20% up to $90 per prescription | not covered
Medical Plan Documents
Access Your EOB (Explanation of Benefit Form)
- HNAS for medical claims
- Email for claims inquiry: claims.hnas@hnas.com
- Call for claims inquiry:
1-800-220-2600
As an Anthem participant, you have access to LiveHealth Online. LiveHealth Online gives you 24/7/365 access to U.S. board certified doctors through the convenience of phone, video or mobile app visits. It’s an affordable alternative to costly urgent care and ER visits when you need care now. Each Physical consultation is subject to your plan’s regular office visit copay.
NOTE: the state of Idaho does no allow video visits but does allow phone consultations.
LiveHealth Online does not replace your primary physician. It is a convenient and affordable option for quality care.
Visit www.livehealthonline.com