Each employer and/or bargaining unit has created a menu of plans from which you may select your coverage effective October 1 through September 30. You may select a plan from that menu if you are ...
- An active employee or the spouse, registered domestic partner or child of an active employee
- A retiree not yet eligible for Medicare
- The spouse or registered domestic partner of a retiree AND you are not yet eligible for Medicare (regardless of the retiree's Medicare status)
- The only dependent child of a retiree eligible for Medicare
Blue Distinction Center Requirements
Medical costs continuing to skyrocket ... skyrocketing costs lead to continual increases in the cost of coverage (premiums) as well as out of pocket costs. In order to control these costs and ensure high-quality outcomes, the following surgeries are restricted to facilities with certain Anthem designations :
- Hip or Knee Replacement and Cervical/Lumbar Spinal Fusion: Blue Distinction+
- Bariatric Surgery: Blue Distinction or Blue Distinction+
For more information on facility designations, click here.
Value-Based Site of Care Requirements
The maximum benefit amount for the five common procedures listed below is limited when performed at an in-network outpatient hospital. At an in-network outpatient hospital, you will be responsible for facility charges above the maximum benefit, beyond your plan’s out of pocket limits. This limitation applies to the facility fee only; fees paid to physicians or any other practitioners who assist in the procedure are not affected by this provision.
|Upper GI Endoscopy w/ Biopsy
|Upper GI Endoscopy
- If you use an Ambulatory Surgery Center (ASC) for these procedures, you will only be responsible for the regular deductible and coinsurance amounts.
- If you use an in-network outpatient hospital facility, you will be responsible for the regular deductible and coinsurance PLUS any amount by which the hospital’s facility charge exceeds the maximum benefit above.
In the following cases, an exception may be granted. Consult your provider and AmeriBen:
- If your physician provides clinical justification for using a hospital.
- If you live more than 30 miles from an ASC.
- If your procedure cannot be scheduled in a medically appropriate timely manner due to available ASCs not having capacity.
- In an emergency.
The physician performing the procedure must apply for one of the exceptions above, in advance of your procedure, by contacting AmeriBen Provider Services directly at 877-379-4845.
Call AmeriBen Members Services at 877-379-4844 for additional information.
Plan Election Cyle
Plan elections are effective October 1 through September 30. When you change your medical benefit, the amounts accumulated towards your benefit limits or maximums as of September 30 may carry over to your new benefit effective October 1.
Plan Limit Cycles (Deductibles & Out-of-Pocket Maximums
Plan deductibles and out-of-pocket limits accumulate on a calendar year basis, from January 1 through December 31. Non-HSA plans carryover amounts applied to the deductible only between October 1 and December 31 to the following calendar year’s deductible.
If you change your medical plan, the amount accumulated towards your benefit limits or maximums as of September 30 may carry over to your new benefit effective October 1.
When you move from a non-HSA plan to another non-HSA plan (i.e. 80% M $40 to 80% J $30) OR an HSA plan to another HSA plan (i.e. MEC HSA to HSA B)...
The amounts accumulated toward your medical and prescription deductibles and out of pocket maximums through September 30 WILL be applied to your elected benefit as of October 1.
When you move from an HSA plan to a non-HSA plan (i.e. MEC HSA to 80% J $30)...
The amount accumulated toward your deductible and out-of-pocket maximums for medical claims incurred through September 30 WILL be applied to your elected benefit as of October 1. Prescription claims are not eligible to transfer. Depending on your accumulator totals, you may or may not have any additional deductible and/or out-of-pocket amount to meet as of October 1. Your limits will reset on January 1 when the annual plan limit cycle begins.
When you move from a non-HSA plan to an HSA plan (i.e. 80% J $30 to MEC HSA)...
The amounts accumulated toward your deductible and out-of-pocket maximums through September 30 WILL NOT be applied to your elected benefit as of October 1, in accordance with IRS regulations. Your HSA plan deductible and out-of-pocket limits will reset to $0 on October 1 and again on January 1 when the annual plan limit cycle begins.
If you would like a more detailed document on your medical plan exclusions and coverages, please contact the BSSP office at 530-879-7438.