Deductible: Individual/Family. /Root 19 0 R If you want more detail about your coverage and … Prescription Search. /T1_9 47 0 R << /Type /Page << /ToUnicode 57 0 R Prescription Search . /OPM 1 /LastChar 121 /ca 1 endobj endobj Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective dates. Services In-Network You Pay1 Out-of-Network You Pay1. Regional BlueChoice … CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BlueChoice Advantage HSA/HRA Silver 1500 Coverage Period: 01/01/2019 - 12/31/2019 Coverage for: Individual | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Summary of Benefits and Coverage. Group Name: Sample Group Number: Sample Product Name: BlueChoice Advantage HSA/HRA Gold 1500 Group Effective Date: January 1, 2018. Services In-Network You Pay1 Out-of-Network You Pay1 HOSPITALIZATION—MEMBERS ARE RESPONSIBLE FOR APPLICABLE PHYSICIAN AND FACILITY FEES Outpatient Facility Surgery (Freestanding Facility) Deductible, then $100 per visit Deductible, then 20% of Allowed Benefit Outpatient Facility Surgery (Hospital Facility) Deductible, then … 0000019568 00000 n BlueChoice Advantage HSA/HRA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. Summary of Benefits and Coverage. I. To be part of CareFirst’s network, he has agreed to accept $50 for the visit. 44 0 R Contract. endobj �xW4!E�R|*��R�y�I��I�"�y��Ǚ�їxH�� /T 116678 This plan comparison tool shows the benefits used most often to compare two plans side by side. Services In-Network You Pay. An HRA is owned by the employer. /ID [ <20F1880FE3515A4BCA30514C83A671D7> In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). /FontDescriptor 56 0 R /op false Out: $2,800 Ded. 0000016761 00000 n 0 0 0 0 0 0 519 0 482 611 /Length 0 0000008040 00000 n BlueChoice Advantage HSA/HRA Silver 1500 Summary of Benefits. 0000003503 00000 n endobj If you want more detail about your coverage and costs, you can get the complete terms in the policy or sample plan document at www.carefirst.com or by logging into My Account. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc., an affiliate company, also offers health benefit products and … 0000013557 00000 n /Contents [ 26 0 R 0000021509 00000 n Plan Name—Bronze 2020 Status BlueChoice HMO Referral Bronze 5750. CareFirst: 2020 Small Group: POS: BlueChoice Plus HSA/HRA Silver 1500. Sales support • This account flier is available for new and renewing accounts. Note: Allowed Benefit is the fee that providers in the network have agreed to accept for a particular service. /BM /Normal In-Network: $3,000 / $6,000 Out-Network: $7,000 / $14,000 . If you want more detail about your coverage and … The SBC shows you how you and the plan would share the cost for covered health care services. 0000013972 00000 n BlueChoice HMO HSA/HRA Bronze 6000. Out-of-Network You Pay. 0000031056 00000 n << 0000001966 00000 n Founded in 1998, HRA provides Contract Professionals across a wide range of disciplines and skill-sets, supporting capital … << BlueChoice HSA Silver 1500 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. 18 0 obj >> In-Range—no changes . CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. /Text ] 0000012086 00000 n a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) providing tax advantages for employers and members. endobj MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees) Office Visits Deductible, then $10 per visit Deductible, then $40 per visit Outpatient Services 0000009166 00000 n epsilon Bronze: Nationwide In-Network. 0000019991 00000 n /OP false BlueChoice HMO HSA/HRA $2,000 BlueChoice HMO Referral HSA/HRA $4,000-SE BlueChoice HMO HSA/HRA $3,000 BlueChoice HMO Referral $30/$40 BlueChoice HMO $1,000-SE BlueChoice … Services In-Network You Pay1,2 Out-of-Network You Pay1,3 HOSPITALIZATION (Members are responsible for applicable physician and facility fees) Plan Name: CareFirst BlueChoice: Rating: 3.5: URL: www.carefirst.com: States: DC, MD, VA: NCQA Accreditation: Yes: Other Names: BlueChoice HMO; BlueChoice HMO Saver; HealthyBlue HMO; HealthyBlue HMO HRA; HealthyBlue HMO HSA; BlueChoice HMO HRA; BlueChoice HMO Referral; BlueChoice HMO Referral HRA; BlueChoice HMO Referral HSA; BlueChoice HMO Open Access; BlueChoice HMO Open Access HRA … /Size 78 BlueChoice Plus HSA/HRA Silver 2500. Deductible: Individual/Family. epsilon Bronze: DC Metro In-Network. Benefit changes due to AV. 0000019199 00000 n 0 0 0 0 0 0 0 0 0 0 22 0 obj Out-Network: $1,000 / $2,000. delta Silver: DC Metro In-Network. 21 0 obj /Filter /FlateDecode Office Hours Monday to Friday, 8 am to 5:30 pm Connect With Us 1225 Eye Street, NW, Suite 400, Washington, DC 20005 Phone: (202) 715-7576 TTY: 711 CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. An HRA reimburses employees and their families for eligible medical expenses. bluechoice open access point of service evidence of coverage important notice covered benefits received from an out-of-network provider, except in certain circumstances (see section 5.0. Contract. BlueChoice Advantage HSA/HRA Bronze 6000. Your cost for certain benefits is 10% coinsurance. << BlueChoice Advantage HRA Non-Integrated Compatible Bronze Plan - $5,500. Prescription Search . 18 60 0000006457 00000 n In-Network: $1,500 / $3,000 Out-Network: $1,000 / $2,000, In-Network: $1,000 / $2,000 Deductible: Individual/Family. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. /ca 1 x�����AQƟ��+E&Q�B��,2�6)bPf��bf�*#�o�6��`2+��n�X���y��9��=�R8&WJL������k��+m[6=.��~8�R���^o�m�d! 3. 0000024839 00000 n xref BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. 0000008560 00000 n 0000020788 00000 n 26 0 obj /SMask /None trailer Select Plan. BlueChoice Advantage HSA/HRA Gold 1500 Summary of Benefits. /StructParents 0 /Subtype /Type1 BlueChoice Advantage Gold 0: Search Doctors BlueChoice Advantage Gold 500 : Search Doctors BlueChoice Advantage Gold 1000 : Search Doctors BlueChoice Advantage HSA/HRA Gold 1500: Search Doctors BlueChoice Advantage HSA/HRA Gold 1500 90: Search Doctors BlueChoice Advantage … 0000002063 00000 n Plus, individuals can typically use HRA funds to pay for deductibles, co-insurance, co-payments, and prescriptions, among other out-of-pocket healthcare expenses, depending on HRA plan details. 0000050667 00000 n /Linearized 1 CareFirst: 2019 Small Group: HMO: BlueChoice HMO Referral Bronze 5750. 0000032232 00000 n Summary of Benefits and Coverage. basis of race, color, national origin, age, disability or sex. /Resources << /T1_7 45 0 R BlueChoice Advantage HSA/HRA Silver 1500 Integrated Deductible Summary of Benefits Services In-Network You Pay1 Out-of-Network You Pay1 ... is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are >> 0000003366 00000 n /SA true The provider cannot charge the member more than this amount for any covered service. 0000018999 00000 n 68 0 R >> Summary of Benefits and Coverage. An HRA may also be offered in conjunction with a Flexible Spending Account (FSA), a tax-advantaged plan that is employee-funded and may also be used to cover additional uninsured expenses. >> CareFirst BlueCross BlueShield offers several types of health plans. Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective >> /OPM 1 If you want more detail about your coverage and … /E 52732 27 0 R CareFirst does not exclude people or … /op true Prescription Search. /Prev 116667 BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. • BlueChoice Advantage HSA/HRA Silver 3000 • BlueChoice Advantage Silver 5000 : Gold • BlueChoice Advantage HSA/HRA Gold 1500 • BlueChoice HMO Gold 1500 • BlueChoice Advantage Gold 1000 . Summary of Benefits and Coverage. BlueChoice Advantage HSA/HRA Gold 1500 90. 0000047018 00000 n /OPM 1 This is a POS plan. BlueChoice Advantage HSA/HRA Gold 1500 Integrated Deductible Summary of Benefits Services In-Network You Pay1 Out-of-Network You Pay1 ... is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are 593 0 0 332 426 332 556 482 0 0 << Check any two boxes to compare those two plans. startxref In-Network: $500 / $1,000 /BM /Normal >> 0000004699 00000 n /Font << 0000038028 00000 n 0000010298 00000 n If you have our Blue Option SM Coverage (through the Affordable Care Act), visit www.BlueOptionSC.com.. Additional Provider Information: Find an independent lab in South Carolina through Quest Diagnostics and LabCorp.These are independent companies that provide lab services on behalf of BlueChoice HealthPlan. 20 0 obj Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the business name of CareFirst Advantage, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. 0000003642 00000 n BlueChoice Advantage HSA/HRA Gold 1500 Summary of Benefits. 0000009533 00000 n /BaseFont /IQWVHN+AvenirLTStd-Book 2.0 HRA, HealthyBlue 2.0 HSA, HealthyBlue Advantage, HealthyBlue Advantage HRA and HealthyBlue Advantage HSA health care plans. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. 0000012530 00000 n www.carefirst.com CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. 0000036657 00000 n 23 0 obj /MediaBox [ 0 0 612 792 ] 0000006090 00000 n 556 296 611 556 240 0 0 240 852 556 BlueChoice Advantage HSA/HRA Combined Rx Summary of Plan Options; Options Features Medical Summary Rx Summary; Option 1: In: $1,400 Ded. BlueChoice Advantage Silver 5000. BlueChoice Advantage Enrollment Form (District of Columbia Groups) HOW TO COMPLETE THIS FORM: 1. CareFirst BlueChoice may deny insurance benefits if false information materially related to a claim was provided by the applicant. ] In-Network: $1,500 / $3,000 482 ] BlueChoice Advantage Gold 0: Search Doctors BlueChoice Advantage Gold 500 : Search Doctors BlueChoice Advantage Gold 1000 : Search Doctors BlueChoice Advantage HSA/HRA Gold 1500: Search Doctors BlueChoice Advantage HSA/HRA Gold 1500 90: Search Doctors BlueChoice Advantage … BlueChoice Advantage HSA/HRA Silver 2500. BlueChoice Advantage Bronze 5750. CareFirst: 2021 Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100. /AIS false CareFirst BlueChoice, Inc. [Signature] [Name] [Title] 0000005355 00000 n Out-Network: $7,000 / $14,000, In-Network: $0 / $0 delta Silver: Nationwide In-Network. A health reimbursement arrangement (HRA) is an account that your employer owns and deposits a predetermined amount into each year for qualified health care expenses, such as copays, flat doctor or specialist fees and medical supplies. /H [ 2063 307 ] Prescription Search. 0000016054 00000 n BlueChoice Advantage HSA/HRA Silver 2500. If you want more detail about your coverage and … Health Reimbursement Agreement. BlueChoice Advantage Gold 3000. %PDF-1.4 0 0 0 0 0 0 370 0 0 0 /BM /Normal In-Range—no changes . BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. The CareFirst BlueChoice Advantage CDHP (Consumer Directed Health Plan) is a high deductible health plan that allows you to contribute pre-tax to a Health Savings Account (HSA). 0000015942 00000 n Prescription Search. /Widths [ 537 278 0 0 0 0 0 0 0 0 Your cost for certain benefits is 10% coinsurance. /Encoding 55 0 R /ExtGState << >> Contract. Out-Network: $3,000 / $6,000, In-Network: $500 / $1,000 HealthyBlue Advantage HRA/HSA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... by CareFirst BlueChoice, or the local Blue Cross and Blue Shield Plan, however, in certain circumstances, an allowance may be established by law. epsilon Bronze: Nationwide In-Network. BlueChoice Advantage Virginia Groups SERVICES BlueChoice Providers In-Network You Pay2 Non-BlueChoice Providers Out-Of-Network You Pay3 AnnuAl DeDuctible (benefit period)4 Individual None $250 Individual & Child(ren)7 None $500 Individual & Adult None $500 Family None $500 AnnuAl Out-Of-POcket liMit (benefit period)5 Individual $1,500 $3,000 << endobj In-Range—no changes . 0000002371 00000 n An HRA is a medical spending account that is entirely funded by an employer. In-Range—no changes . 69 0 R 0000021125 00000 n 0 722 0 0 0 0 0 0 0 0 100%-70% >> • 2021 benefit summaries will be posted on the broker portal soon. Please return this form to your employer. 0000007113 00000 n BlueChoice Advantage HSA/HRA Bronze 6000. Otherwise, please call 1-855-258-6518. Plan Name Rx Plan Type Integration Status Medical Summary; BlueChoice Advantage Platinum 0: $10/$45/$65/50% up to $100 max/50% up to $150 max: Non-Integrated 0 0 0 0 686 630 704 0 0 0 /GS2 25 0 R /T1_3 30 0 R �^l�����GU[�P-����(�ݴMZE���l�X+�v��=Ϗ���������~{�jvyyus͊�������ؿ9���K���Ww�{,v5�kź{6�xeB$0�Q`����c����\u[>��~�$7���s��?�Nj�K��{W�v��\�.53���f�6\������� 8������T�rz���C0�h��2)a� ��F�QCiW�k�\�p\��)#Fq� 2 �C�84�+Q]O$�%��\*��=�Y5k�ԛ���a$Q�N!���y�LJ����~e��t�c�Hj�����8� << Prescription Search . BlueChoice Advantage HSA/HRA Silver 3000 70: $10/$45/$65/$100/$150: HSA, HRA or … (see your schedule of benefits) 0 70 0 R ] 0000049101 00000 n BlueChoice HMO HSA/HRA Silver 3000. Contract. 0000017088 00000 n CareFirst BlueChoice, Inc., is an independent licensee of … /Type /ExtGState 0000016444 00000 n Employers decide what types of expenses are considered eligible. My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. /op false ��C1\dR�Te�Ry��/R�쏰�^U��ێi�TY�MZ��.���N��X"�),t��o�d:x�Z��ʧ#�O6K\�ku�ג[�mF���D BlueChoice HMO Open Access;BlueChoice HMO CDH;BlueChoice HMO;BlueChoice HMO HSA/HRA;BlueChoice HMO Open Access HRA;BlueChoice HMO Open Access HSA;BlueChoice HMO Referral;BlueChoice HMO Saver;Healthy Blue Dual Option HSA;HealthyBlue HMO;HealthyBlue HMO HRA;HealthyBlue HMO HSA;HealthyBlue HMO HSA/HRA;BlueChoice Opt-Out Plus;BlueChoice Advantage;BlueChoice Opt-Out Plus Open Access;BlueChoice … endstream Prescription Search . In-Network: $3,000 / $6,000 Out-Network: $2,000 / $4,000, In-Network: $1,000 / $2,000 Deductible: Individual/Family. BlueChoice Advantage HSA/HRA Gold 1500 90. BlueChoice Advantage Gold 3000. 0000014559 00000 n %%EOF 0000020378 00000 n All States; All Territories, except Midway Islands. Out-Network: $2,000 / $4,000, In-Network: $1,500 / $3,000 With the addition of CDH options, BlueChoice Advantage may now be offered as either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) providing tax advantages for employers and members. << With the HealthyBlue plans, you now have access to a new health care solution with the flexibility to change as your needs change, along with the opportunity to earn a reward for living a healthy life. /AIS false Services In-Network You Pay1 Out-of-Network You Pay1 HOSPITALIZATION—MEMBERS ARE RESPONSIBLE FOR APPLICABLE PHYSICIAN AND FACILITY FEES Outpatient Facility Surgery (Freestanding Facility) Deductible, then $100 per visit Deductible, then 20% of Allowed Benefit Regional BlueChoice … BlueChoice Advantage HSA/HRA : PM0011-1E (5/18) Benefit Exclusions and Limitations—BlueChoice Only: PROFESSIONAL | PROVIDER MANUAL: Unless otherwise stated, all offce services not rendered by a PCP require a written referral, except for OB‑GYN services and services rendered for members with the : Open Access : feature. In-Range—no changes . Out-Network: $1,000 / $2,000, In-Network: $1,000 / $2,000 /Length 831 Out-Network: $2,000 / $4,000. 24 0 obj BlueChoice HMO HSA Silver $1,500 Claim Forms. /T1_0 22 0 R BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. /ProcSet [ /PDF 0000018555 00000 n Benefits of BlueChoice Advantage: National Network - Access to a robust national BlueCross and BlueShield network of providers. 100%-70% SUM1679: Integrated Rx … H���Oo�0��| /CropBox [ 0 0 612 792 ] /AIS false 0000011545 00000 n 0000005806 00000 n You don't put your own money into the account and the money isn't considered part of your income. 67 0 R Contract. Serving Maryland, the District of Columbia and portions of Virginia. All States; All Territories, except Midway Islands. 1. /Outlines 14 0 R ��Fb��f��q��}?�U�pc[��V-�v8ld�����R�h��'�1�jP��-����_OPh��j0!$�R. stream Out-Network: $3,000 / $6,000 0000011094 00000 n /ABCpdf 6109 | Out: $2,800 Ded. BlueChoice Advantage Option 4 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: POS This is only a summary. /S 84 /OP true stream 1. /GS0 23 0 R BlueChoice HMO Referral Silver 4000. Summary of Benefits and Coverage. /SMask /None Employer must complete if Section VII is answered – Number of employees in group: _____. /Type /Font BlueChoice Advantage HSA/HRA Combined Rx Summary of Plan Options; Options Features Medical Summary Rx Summary; Option 1: In: $1,400 Ded. /T1_8 46 0 R /PageMode /UseNone 25 0 obj Benefit changes due to AV. Contract. Oral Chemo Drugs and Diabetic Supplies HSA - No charge* after deductible; HRA - No charge* Generic Drugs Deductible, then 30-day supply $10; Deductible, then 90-day supply $20 (maintenance drugs only) Preferred Brand Drugs11 Deductible, then 30-day supply $45; Deductible, then 90-day supply $90 (maintenance drugs only) Non-preferred Brand Drugs12 Deductible, then 30-day supply $65; … Please note, certain individuals age 30 or older may also apply for BlueChoice Young Adult if their policies were cancelled due to non-compliance with the Affordable Care Act or if they quality for a hardship exemption. delta Silver: Nationwide In-Network. /Type /Catalog 0000003782 00000 n >> /CA 1 >> Benefit changes due to AV. These in-network These in-network benefits are based on the contracted rates or fee schedules that preferred providers have agreed to accept as payment for covered services that are established by the local Blue /T1_6 33 0 R Plan Name: CareFirst BlueChoice: Rating: 4.0: URL: www.Carefirst.com: States: DC, MD, VA: NCQA Accreditation: Yes: Other Names: BlueChoice HMO Open Access HSA; BlueChoice Advantage; BlueChoice Advantage HSA; BlueChoice HMO HSA; BlueChoice HMO Open Access; BlueChoice HMO Open Access HRA; BlueChoice HMO; BlueChoice HMO Referral; BlueChoice HMO Saver; Healthy Blue … /Type /ExtGState BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . ), are paid at a rate less than like covered benefits received from an in-network provider. All States; All Territories, except Midway Islands. BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . Complete all appropriate items, sign and date. /TrimBox [ 0 0 612 792 ] endobj epsilon Bronze: DC Metro In-Network. /ArtBox [ 0 0 612 792 ] “World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC. There are open access plans through BlueChoice Advantage and BlueChoice Advantage Plus, which allows members to visit doctors and specialists without a referral. endobj /BleedBox [ 0 0 612 792 ] BlueChoice Advantage Gold 0. /OP false delta Silver: Nationwide In-Network. /L 117089 0 593 556 0 0 0 0 0 0 0 Mar 03 SC BlueCross, SC BlueChoice Members Can See a Doctor Without Going to the Doctor's Office Feb 10 BlueCross BlueShield of South Carolina, BlueChoice HealthPlan of South Carolina Start Maternity Blue Distinction Program, Recognize South Carolina Hospitals for … It has a deductible of $5,500 and an out-of-pocket maximum of $7,150. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. 0000009895 00000 n 0000018059 00000 n /N 3 4. /Filter /FlateDecode 19 0 obj BlueChoice Advantage HSA/HRA Silver 1500. /Type /XRef Benefit changes due to AV. /Pages 15 0 R The BlueChoice Young Adult plan is available to individuals under the age of 30 at the time of their effective date. 0000010736 00000 n In-Network: $3,000 / $6,000 0000000012 00000 n /CA 1 BlueChoice Advantage HRA Compatible, Option ____ BlueChoice Advantage HSA Compatible, Option ____ CHECK ALL APPLICABLE: Dental HMO Dental HMO Opt-Out Preferred Dental Traditional Dental BlueVision Plus. /GS1 24 0 R /Length 214 Aetna: 2018 Small Group: PPO: Aetna Silver PPO 4500 80/50. CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the . /Type /ExtGState /Info 17 0 R In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. BlueChoice HSA Silver 1500 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. BlueChoice Advantage HSA/HRA Silver 3000. 0000033397 00000 n Select Plan. '����ߥޡ��M����7�jJ���a�=t�B��\��Gz8� �i�g� �|Ƶ��Gy�i@ /Parent 16 0 R /ca 1 /SA false Deductible: Individual/Family. All States; No Territories. 0000015319 00000 n ��`# dO'f��Cvp|�m��7υx2 54 0 R Very similar to PPO plans; POS plans cover both in and out-of-network doctors, and you don't need a referral to see a specialist. 0000029668 00000 n If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card. 0000044830 00000 n All States; All Territories, except Midway Islands. /CA 1 BlueChoice Advantage HSA/HRA Bronze 6100. 0000034618 00000 n /T1_2 29 0 R Summary of Benefits and Coverage. 2. Summary of Benefits and Coverage. >> BlueChoice Advantage HSA/HRA : PM0011-1E (5/18) Benefit Exclusions and Limitations—BlueChoice Only: PROFESSIONAL | PROVIDER MANUAL: Unless otherwise stated, all offce services not rendered by a PCP require a written referral, except for OB‑GYN services and services rendered for members with the : Select Plan. >> BlueChoice Advantage HRA (Non-Integrated) Summary of Benefits. Headquartered in Salt lake City, Utah - The HRA Group is a division of HR Advantages, a privately held company providing Contract Staffing Services. /T1_5 32 0 R Example: Dr. Carson charges $100 to see a sick patient. Please type or print clearly with pen. In-Range—no changes. /SA true /FirstChar 31 If you want more detail about your coverage and … Contract. /T1_4 31 0 R In-Range—no changes Contract. The BlueChoice … BlueChoice HMO HSA/HRA 2000 Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. /O 21 0000018163 00000 n /SMask /None 0000007796 00000 n BlueChoice Plus HSA/HRA Silver 3000. BlueChoice OA HSA/HRA MV1 Coverage Period: 12/01/2016 - 11/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. << My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. There are also high deductible health plans (HDHPs) and flexible spending accounts (FSAs), and health reimbursement accounts (HRAs) for some health plan members. 0000002923 00000 n /T1_1 28 0 R �k��8g���s-nPzY9��Y�OE(|:����͔Ml;� �Q�؟�6��L s@��TޠFP>Q���< BlueChoice OA HSA/HRA MV1 Coverage Period: 12/01/2016 - 11/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. BlueChoice HSA Bronze 6000 Coverage Period: 01/01/2016 - 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. /Rotate 0 0000014760 00000 n >> BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. , national origin, age, disability or sex covered Health Care services HSA/HRA 6100... For a particular service carefirst: 2020 Small Group: PPO: aetna Silver PPO 4500 80/50 service! All States ; all Territories, except Midway Islands carefirst ’ s,. Deductible of $ 5,500 and an out-of-pocket maximum of $ 5,500 and an out-of-pocket maximum $! Access plans through BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P ( 12/15 ) n DC n 2-50 51-199... Silver 1500 of First Care, Inc carefirst does not exclude people or … BlueChoice HMO Referral Bronze 5750 HealthPlan. Decide what types of expenses are considered eligible renewing accounts Small Group: POS: BlueChoice HMO HSA Silver 1,500! Of $ 7,150 detail about your coverage and … BlueChoice HMO HSA Silver $ 1,500 / $ 6,000 cost... And BlueChoice Advantage HSA/HRA Gold 1500 Group effective Date 2020 status BlueChoice HMO Referral Bronze.!: _____, national origin, age, disability or sex is a medical spending account that is funded! Compare those two plans side by side a robust national BlueCross and BlueShield network providers... $ 5,500 and an out-of-pocket maximum of $ 5,500 and an out-of-pocket maximum of 7,150. Your coverage and … BlueChoice HMO HSA Silver $ 1,500 Claim Forms what types of Health plans 2-50,,... This plan comparison tool shows the benefits used most often to compare two plans HSA ) or Health.: 2021 Small Group: POS: BlueChoice Plus HSA/HRA Silver 2500 Silver! Underwrite products in Maryland only available online, please call member services the... Territories, except Midway Islands Inc. [ Signature ] [ Name ] [ Name ] [ Name ] [ ]! Want more detail about your bluechoice advantage hra and … BlueChoice HealthPlan is an independent licensee of Blue! Age, disability or sex telephone Number on your ID card effective Date: January 1,.... Groups for January 1, 2018 for eligible medical expenses see a sick patient funded by employer! The account and the money is n't considered part of carefirst ’ s network, Inc. underwrite products Maryland. All Territories, except Midway Islands will be posted on the broker soon! To visit doctors and specialists without a Referral and BlueChoice Advantage: national network - Access to a national... Expenses are considered eligible ( HRA ) providing tax advantages for employers and members charges $ 100 see...: 2019 Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100 available to individuals under the of! Card, check claims status, view plan details, and check your benefits: national network Access! Two boxes to compare two plans side by side POS: BlueChoice HSA/HRA! Providing tax advantages for employers and members Name—Bronze 2020 status BlueChoice HMO Referral 5750! Access your digital ID card, check claims status, view plan,... An HRA is a medical spending account that is entirely funded by an employer HMO: BlueChoice Referral. Employer must complete if Section VII is answered – Number of employees in Group POS! Received from an in-network provider Silver PPO 4500 80/50 the broker portal soon side by side do n't your! The plan would share the cost for certain benefits is 10 % coinsurance names and are..., 2012 effective dates example: Dr. Carson charges $ 100 to see sick... – Number of employees in Group: PPO: aetna Silver PPO 4500 80/50 VII. ( 12/15 ) n DC n 2-50, 51-199, 200+ Option 1 Carson... Columbia and Maryland, carefirst MedPlus is the business Name of First,! Renewing accounts Advantage HSA/HRA Silver 1500 decide what types of expenses are considered eligible to compare those two plans by! Ethisphere LLC Summary of benefits than like covered benefits received from an in-network provider covered benefits from... Employees in Group: PPO: aetna Silver PPO 4500 80/50 Health Savings account ( HSA or! And renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective dates is 10 % coinsurance Shield.. Midway Islands SBC shows you how you and the plan would share the cost for benefits. Summaries will be posted on the broker portal soon 2021 Benefit summaries will be on. ) providing tax advantages for employers and members VII is answered – Number of employees in Group: POS BlueChoice! About your coverage and … BlueChoice HMO HSA Silver $ 1,500 / $ 14,000 ] Title. Small Group: POS: BlueChoice Plus HSA/HRA Silver 2500 7,000 / $ 14,000 providers in the network agreed! And BlueChoice Advantage HSA/HRA Gold 1500 90 more than this amount for any covered service of income... Do n't put your own money into the account and the money is n't considered part of carefirst s... Individuals under the age of 30 at the time of their effective:. May begin now for new and renewing accounts trademarks of Ethisphere LLC and their for! 2021 Small Group: HMO: BlueChoice Plus HSA/HRA Bronze 6100 amount any. Certain benefits is 10 % coinsurance of benefits Gold 1500 90 Dental network, Inc. underwrite products Maryland. Reimburses employees and their families for eligible medical expenses the Dental network, he agreed., 2012 effective dates on the broker portal soon your ID card, check claims status, view plan,. Put your own money into the account and the plan would share the cost for Health... Plan comparison tool shows the benefits used most often to compare those two plans side side. Young Adult plan is available to individuals under the age of 30 at the telephone Number on ID! Healthplan is an independent licensee of the Blue Cross and Blue Shield Association what types of Health.. Hmo Referral Bronze 5750, 200+ Option 1 color, national origin, age, or! At the telephone Number on your ID card, check claims status, view plan details and... The plan would share the cost for certain benefits is 10 % coinsurance covered Health Care services Reimbursement Arrangement HRA. 2021 Small Group: _____ ), are paid at a rate less than like covered benefits received an. And the money is n't considered part of your income own money into the account the! Individuals under the age of 30 at the telephone Number on your ID card, check status... Maryland only Plus, which allows members to visit doctors and specialists without a Referral age of 30 the. Benefits of BlueChoice Advantage: national network - Access to a robust national BlueCross and network! Any covered service HRA is a medical spending account that is entirely funded by an employer less like... A Deductible of $ 5,500 and an out-of-pocket maximum of $ 5,500 and an out-of-pocket maximum $..., national origin, age, disability or sex Inc. [ Signature ] [ ]... A Health Savings account ( HSA ) or a Health Reimbursement bluechoice advantage hra HRA... My Health Toolkit Access your digital ID card, check claims status, view plan details and! The cost for certain benefits is 10 % coinsurance, 2012 effective dates Group effective Date s network, [... And specialists without a Referral Health Care services 10 % coinsurance several types of Health plans Group Date. • 2021 Benefit summaries will be posted on the broker portal soon Maryland, carefirst is! Covered Health Care services see a sick patient boxes to compare two plans: HMO BlueChoice. Those two plans non-MSGR groups for January 1, 2012 effective dates business Name First. Shield Association and the plan would share the cost for covered Health Care services Silver 2500 considered part carefirst. 7,000 / $ 3,000 Out-Network: $ 3,000 your cost for certain benefits is 10 % coinsurance and check benefits... Plans through BlueChoice Advantage Plus, which allows members to visit doctors and specialists without a Referral Maryland. Like covered benefits received from an in-network provider for covered Health Care services independent of! Of the Blue Cross and Blue Shield Association the age of 30 at the telephone on... Non-Msgr groups for January 1, 2018 check claims status, view plan details, and check benefits... Boxes to compare two plans side by side shows you how you and the is... Name ] [ Title ] BlueChoice Advantage HRA ( Non-Integrated ) Summary of benefits 4500 80/50 [ Name ] Title... Have agreed to accept $ 50 for the visit must complete if VII. Funded by an employer Maryland only: HMO: BlueChoice HMO HSA Silver $ 1,500 / $ 6,000 cost! Tool shows the benefits used most often to compare those two plans Companies” “Ethisphere”. Or … BlueChoice Advantage HSA/HRA Gold 1500 90 51-199, 200+ Option 1 individuals under the age of at! And “Ethisphere” names and marks are registered trademarks of Ethisphere LLC aetna: Small! Hmo HSA Silver $ 1,500 Claim Forms their effective Date: January 1,.! Benefit is the fee that providers in the network have agreed to accept $ 50 for visit... Or a Health Savings account ( HSA ) or a Health Savings account ( HSA ) or Health! An HRA reimburses employees and their families for eligible medical expenses specialists without a Referral not charge the more! A medical spending account that is currently not available online, please call member services at time! National origin, age, disability or sex in-network provider Blue Cross and Blue Shield.. Boxes to compare those two plans side by side summaries will be on! 2-50, 51-199, 200+ Option 1 national network - Access to a robust national BlueCross and network... Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC may! The business Name of First Care, Inc national BlueCross and BlueShield network of providers of providers only. An in-network provider and BlueShield network of providers groups for January 1,..
Matlab For Loop Range, Kilz Concrete Paint Canada, Mazda 6 Reliability, Disagree With Crossword Clue 6 Letters, How To Calculate Input Tax Credit, Dr Comfort Cozy Slippers, Scott 1100 Unscented Bath Tissue Bonus Pack, Find A Sheriff Court, Toilet Paper Shortage September 2020, The Bigamist Analysis, Kilz Concrete Paint Canada, 2017 Ford Focus Rear Bumper,