Blueprint HD

Blueprint
HD
A self-funded PPO plan with
HSA-qualified options for
small employer groups
Blueprint provides a program to establish and maintain a
self-funded health plan coordinated with stop-loss insurance
protection for employers with 10 to 50 employees.
Note: This plan overview must be presented with the
Blueprint brochure (IHC BGH 1213).
IHC BGH HD 1213
Plan options
Design your group’s health plan using the following options. Not all benefit combinations are possible.1
Physician office visit
If selected, the copay applies to the physician
consultation charge per PPO visit with a primary
care physician, a specialist or at an urgent care
facility. After the copay, the plan pays 100 percent
of the balance of the office visit
consultation charge. Other covered services
performed during the visit are subject to the
deductible and payment percentage.
Primary Care Physician/Specialist/Urgent Care Copay
$20/$40/$50NQ
$30/$50/$50NQ
$40/$60/$50NQ
No copay; covered charges apply to the deductible and
payment percentage
Deductible
The deductible options listed apply per plan
member to covered PPO charges within the
plan year. Covered charges for all covered
family members accumulate to satisfy the family
deductible within the plan year. PPO and nonPPO deductibles accumulate separately.
IndividualFamily
$1,500$3,000
$2,000$4,000
$2,500$5,000
$3,000$6,000
$3,500$7,000
$5,000$10,000
Non-PPO provider visit: Deductible and payment percentage
Non-PPO deductible: Two times the PPO deductible amount
Family deductible1: When family coverage is elected, the family
deductible must be fully satisfied within the plan year before
covered charges are applied to the payment percent.
Payment percentage
After the deductible has been satisfied, the plan
will pay the selected payment percentage of
covered PPO charges.
100%
90%
80%
70%
50%2
Non-PPO payment percentage: 70% for the 100% and 90% PPO
options, 60% for the 80% PPO option, and 50% for the 70% and
50% PPO options
Payment percentage limit
After the deductible has been satisfied, the plan
member is responsible for the selected individual
payment percentage limit for covered PPO
charges per plan year. Covered charges applied
to the selected payment percentage for all
covered family members accumulate to satisfy
the family limit within the plan year. PPO and
non-PPO payment percentage limits accumulate
separately.
IndividualFamily
$0$0
$1,500$3,000
$2,000$4,000
$2,500$5,000
$3,000$6,000
$4,000 $8,000
Non-PPO payment percentage limit: Three times the PPO
payment percentage limit. When $0 is selected, the non-PPO
payment percentage limit is $4,500 for an individual and $9,000
for a family.
2014 maximum allowable HSA contribution and out of pocket: $6,350 individual, $12,700 family. For tax-related questions
and/or advice regarding health savings accounts (HSA), please consult your accountant or attourney.
2
50% payment percentage is not available when selecting the GWH-CIGNA Network.
NQ
Benefit selections do not meet federal guidelines for use with a health savings account. The plan year deductible and
payment percentage limits on HSA-qualified plans are subject to annual cost-of-living adjustments as may be required by
federal guidelines to maintain the plan’s eligibility.
1
2
IHC BGH HD 1213
Benefits
Prescription drug coverage
If electing coverage for prescription drugs, select from one of the following five benefit options:
Option 1NQ Generic: $10 copay; Brand: subject to major medical plan deductible and payment percentage;
Specialty drugs: $150 copay
Option 2
Option 3
All drugs apply to major medical plan deductible and payment percentage
NQ
Generic: $10 copay; Brand Formulary: $50 copay; Brand Non-formulary: $100 copay;
Specialty drugs: $150 copay
Option 4 NQ Generic: $10 copay; Brand Formulary: $50 copay and 30% payment percentage; Brand
Non-formulary: $100 copay then 50% of the remaining charge; Specialty drugs: $150 copay
Option 5 NQ Generic: $10 copay; Brand Formulary: $25 copay; Brand Non-formulary: $40 copay;
Specialty drugs: $150 copay
Expenses incurred for the following charges do not accumulate toward the payment percentage limit: inpatient notification penalties and
charges excluded under the self-funded Plan Document. The Payment Percentage Limit is distinct from the Out-of-Pocket Maximum,
which is the amount of Covered Charges, including Deductibles, Copayments and Co-Payment Percentage payments and certain
specific charges for a Balance Bill received from a Provider that the Plan Member must pay per Calendar Year before the Plan begins to
pay benefits for Covered Charges at 100%. The Out-of-Pocket Maximum does not include any charge in excess of the established plan
maximums/limitations, penalties for non-compliance with Plan provisions, and ineligible expenses.
Features
All benefits listed apply per plan member
Preventive services
Covered preventive services are those
rated with an “A” or “B” by the United States
Preventive Services Task Force (USPSTF),
along with immunizations and screenings as
outlined in the self-funded Plan Document.
PPO providers: 100%—covered charges are not subject to the plan copay,
deductible or payment percentage
Outpatient diagnostic tests, lab and X-ray
If a copay is selected—PPO providers: 100% up to $500 per visit, then
subject to the deductible and payment percentage
Non-PPO providers: Not a covered benefit
If no copay is selected—PPO providers: Subject to the deductible and
payment percentage
Non-PPO providers: Subject to the deductible and payment percentage
Ambulance
(Air and ground services only)
Subject to the deductible and payment percentage
Emergency services
Subject to the deductible and payment percentage
In an emergency, as defined by the plan, non-PPO covered charges will
be paid at the PPO benefit level.
Inpatient facilities and surgical services
Subject to the deductible and payment percentage
Maternity services
Subject to the deductible and payment percentage
Physical, speech or occupational therapy
Maximum benefit per plan year of 30 treatments for any one type of
therapy and up to 60 treatments for any combination of therapies.
Benefits are subject to the deductible and payment percentage.
IHC BGH HD 1213
3
Features
All benefits listed apply per plan member
Mental, nervous and substance abuse
disorders1
Covered charges for all mental, nervous and substance abuse disorders
are subject to the deductible and then a 50% payment percentage.
Inpatient mental, nervous and substance abuse care: Maximum benefit of
28 inpatient days per plan year
Outpatient mental, nervous or substance abuse care: Maximum benefit of
$50 per outpatient visit
Organ transplant
Covered human organ and tissue
transplants include those for bone marrow,
cornea, heart, heart-lung, lung, pancreas,
pancreas-kidney, kidney, liver and small
bowel.
Center of Excellence provider: Subject to the deductible and payment
percentage
Chiropractic care
If a physician office visit copay benefit is elected, chiropractic care visits are
subject to the Specialist copay amount up to a maximum benefit of 20 visits
per plan year.
A transportation expense benefit of up to $5,000 is available per transplant
when performed at a Center of Excellence.
Non-Center of Excellence provider: Subject to the deductible and payment
percentage up to a maximum benefit of $100,000 per transplant
If a copay benefit is not elected, chiropractic care is subject to the
deductible and payment percentage up to a maximum benefit of 20 visits
per plan year.
Oral surgery
Subject to the deductible and payment percentage up to a maximum benefit
of $5,000 per plan year
Skilled nursing care
Subject to the deductible and payment percentage up to a maximum benefit
of 60 days per plan year
Home health care
Subject to the deductible and payment percentage up to a maximum benefit
of 60 visits per plan year
Hospice care2
100% after the deductible
1
Covered charges for all mental, nervous and substance abuse disorders are subject to the deductible and then a 70%
payment percentage for PPO and 50% payment percentage for non-PPO when selecting the GWH-CIGNA network. If the
group has more than 50 total employees, mental health benefits are provided the same as any other covered illness.
2
Hospice care is covered at 100% after the deductible for PPO and 80% for non PPO when selecting the
GWH-CIGNA network.
This plan overview is intended as a summary only. Availability
varies by state. For complete details regarding benefits, conditions,
limitations and exclusions that apply, ask your representative for
a sample of the self-funded Plan Document. All benefits are in
compliance with the federal Patient Protection and Affordable
Coverage Act of 2009 (PPACA) and other relevant laws.
IHC BGH HD 1213

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