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4
Medical Insurance – Anthem/Kaiser
Pacific Coast Title Company offers
four
medical plan
options administered by Anthem Blue Cross Blue
Shield or Kaiser Permanente. Anthem BCBS offers a
Health Maintenance Organization (HMO), a Health
Incentive Account (HIA) and a Preferred Provider
Organization (PPO). Kaiser offers an HMO. Anthem
utilizes a national provider network while Kaiser has
a local network serving California residents.
Features of all medical options:
Preventive health care services from a network
provider are covered at 100% and are not
subject to a deductible or copay.
All copays and any deductible amounts apply
towards the out-of-pocket maximum. The
Anthem HIA and PPO plans have separate out-of-
pocket maximums for in and out-of-network
services.
Any licensed provider can provide services;
however, you will receive a much greater benefit
by going to a network provider. The HMOs cover
services received from network providers only.
If an out-of-network benefit is offered (non-HMO
plans), you could be responsible for the amount
charged by the out-of-network provider that is in
excess of the amount that would have been pay-
able if the services were rendered by a network
provider. This is called balance billing for charges
over Usual, Reasonable & Customary.
Features of the HIA Plan:
Includes an integrated Health Incentive Account
administered by Anthem BCBS and funded by
Pacific Coast Title Company to help cover eligible
expenses, including pharmacy, in effect, reducing
the annual deductible amount.
HIA funds are available on day one and can be
used towards your deductible. Once the fund is
exhausted, you pay the remaining deductible
amount (called the Bridge) and a percentage of
the covered expense (your coinsurance) but no
more than the out-of-pocket maximum. Once
you’ve satisfied the out-of-pocket maximum, the
insurance company covers 100% of any covered
expense for you and/or your family members for
the rest of the plan year.
Features of the HIA Plan continued:
If you elect “Employee Only” coverage, the
deductible is limited to the plan “Individual”
deductible. If you elect to cover yourself and at
least one more family member, you must meet
the “Family” deductible before Anthem BCBS
pays a portion of the expense. One person or
any combination of covered family members can
meet the family deductible.
Features of the HMO Plans:
Offers coverage only when care is received from
a network provider or contracted pharmacy.
Care and treatment should be coordinated
through a Primary Care Physician and most
covered services will require an approval or a
referral from a Primary Care Physician.
Features of HMO and PPO options:
Care from a network Primary Care Physician or
Specialist is offered at a copay.
Prescriptions filled at a network pharmacy are
covered at a copay based on drug tier/category.
For each covered person, the deductible is limited
to the plan “Individual” deductible. If you elect to
cover yourself and at least one more family
member, your total deductible expenses for all
family members will not exceed the “Family”
deductible. Any combination of covered family
members can meet the family deductible.
Under the Anthem BCBS HMO and PPO, non-
preventive health care expenses, not covered by
a copay (inpatient hospitalization for instance),
are subject to the calendar year deductible. Once
you meet the deductible, you pay only a percent-
age of the covered expense (your coinsurance)
and no more than the out-of-pocket maximum.
Once you’ve satisfied the out-of-pocket maxi-
mum, the insurance company covers 100% of
any covered expense for you and/or your family
members for the rest of the plan year.
Under the Kaiser HMO, non-preventive health
care expenses, are covered by a service copay
not to exceed the out-of-pocket maximum. Once
you’ve satisfied the out-of-pocket maximum, the
insurance company covers 100% of any covered
expense for you and/or your family members for
the rest of the plan year.