Response to More FAQ on Medical Insurance

There has been some confusion regarding the HMO plans and at our request, Alliant has provided the following information that some may find useful.

HMO Networks:

     In most areas of California the Classic HMO will have more doctors than the Select HMO.  The network has a lot to do with how the doctors get paid.  Without getting too complicated, a doctor doing the same amount of work gets paid more under the Anthem Classic contract than they would under the Select contract.  Many doctors participate in both the Select and Classic networks, but some doctors choose to only participate with the Classic network due to the difference in payment. 

     In LA and SB counties, some of the more/most expensive HMO doctors only participate in the Classic plan, but there is little or no difference between the networks in Ventura County.  In reality most people will only need to see one or two doctors, so the only thing that really should matter which specific plan your one or two doctor(s) contract with.  If your doctors happen to be in both networks, the Select HMO makes a lot of financial sense.  This is why we encourage everyone to visit the VCDSA/Anthem website (https://enrollment.anthem.com/VCDSA) to check their doctor's status. 

     While Anthem has a vetting process for all of the doctors that it contracts with, from a quality of care perspective, one network isn't better than another.  This is why we encourage the members coming over from a Kaiser plan to take a good look at the Select plan - if they don't have an existing relationship with a specific doctor, they can save a lot of money by picking one that works with the Select network. 

What you can expect to pay with the Select HMO:

     We use a lot of insurance jargon.  So that we’re “speaking the same language,” here are the plan features and costs for the Select HMO Baseline Plan Terms and Cost:

  • Office Visit Copayment: You will pay $25 to see your Primary Care doc and $40 for a Specialist from day 1.  This payment is referred to as a "copayment" and will not change during the year.  Copayments are not subject to the deductible but copayments count toward the out-of-pocket maximum. 
  • Deductible: The Select HMO has an annual deductible of $750 per member that mainly applies to procedures performed in a hospital setting (inpatient stays - for example maternity, outpatient procedures, and emergency room visits).  In a calendar year, you will be responsible for paying for the first $750 of any services subject to the deductible.  This deductible is family member-specific, so each member has his/her own deductible.
  • Coinsurance: Once you've satisfied the $750 deductible, Anthem will split the bill with you.  Anthem will pay 75% of charges and you will be responsible for 25%.  This cost-sharing is referred to as coinsurance.
  • Out-of-Pocket (OOP) Maximum: The plan has an annual out-of-pocket maximum of $3,000 per member.  Once you reach this amount, Anthem pays 100% of covered services and you pay nothing for the remainder of the year.  When Anthem tracks the OOP max, they include all copayments, the deductible and coinsurance: $3,000 is the most each person enrolling on the Select HMO will pay in a calendar year.  Members enrolling in 2-party or family coverage benefit from the family OOP max of $6,000 - this ensures that the collective family will not pay more than $6,000 in a calendar year. 

So let’s apply this to your questions – again in reference to the Select HMO:

  • Number one – do I have to pay 20% of every visit after I reached the deductible for individual or family?

       Remember that office visits are $25 ($40 for specialist) regardless of deductible.  When services are subject to the deductible (mainly hospital), you are responsible for 100% of cost until you’ve met the $750 deductible.  Then you split the bill with Anthem 25/75 until your 25% reaches $2,250 and you hit the $3,000 Out-of-Pocket max.  Here are some scenarios that demonstrate the how the plan works:

  •  Scenario 1 - $5,000 hospital bill: You pay the first $750 (deductible).  Of the remaining $4,250, you pay $1,062.50 (25%) and Anthem will pay $3,187.50 (75%).  So far you’ve paid a total of $1,812.50 ($750 + $1,062.50), and you would be $1,187.50 away from the OOP max.  Because you haven’t reached the OOP max, you would still have to pay $25/40 copays for office visits and the appropriate copays for prescription drugs. 
  •  Scenario 2 - $100,000 hospital bill: You pay the first $750 (deductible).  $99,250 remains.  If we split the bill 25/75, you would be responsible for $24,812.50, but because the OOP max is $3,000, so you only pay an additional $2,250 to meet the $3,000 OOP max ($750 + $2,250 = $3,000).  Anthem pays the rest.  Now that you’ve satisfied the $3,000 OOP max, your cost for office visits, prescriptions and any other covered services will be $0.   
  •  Scenario 3 – Family coverage, $100,000 hospital for you, $5,000 bill for your son:
  •  You: You pay the first $750 (deductible).  $99,250 remains.  If we split the bill 25/75, you would be responsible for $24,812.50, but because the OOP max is $3,000, so you only pay an additional $2,250 to meet the $3,000 OOP max ($750 + $2,250 = $3,000).  Anthem pays the rest.  Now that you’ve satisfied the $3,000 OOP max, your cost for office visits, prescriptions and any other covered services will be $0. 
  • Your son: You pay the first $750 (deductible).  Of the remaining $4,250, you pay $1,062.50 (25%) and Anthem will pay $3,187.50 (75%).  So far you’ve paid a total of $1,812.50 ($750 + $1,062.50), and you would be $1,187.50 away from the $3,000 OOP max.  Because you haven’t reached the OOP max, you would still have to pay $25/40 copays for office visits and the appropriate copays for prescription drugs. 
  • Your other family members, including your son, are protected by the combined family out-of-pocket max of $6,000.  While you have hit your individual out-of-pocket maximum, they will be responsible for copays/costs until they reach the $6,000 family total. 

  •  Scenario 4 – Family coverage, $100,000 hospital for you, $100,000 bill for your son:

    • You: You pay the first $750 (deductible).  $99,250 remains.  If we split the bill 25/75, you would be responsible for $24,812.50, but because the OOP max is $3,000, so you only pay an additional $2,250 to meet the $3,000 OOP max ($750 + $2,250 = $3,000).  Anthem pays the rest.  Now that you’ve satisfied the $3,000 OOP max, your cost for office visits, prescriptions and any other covered services will be $0. 
    • Your son: You pay the first $750 (deductible).  $99,250 remains.  If we split the bill 25/75, you would be responsible for $24,812.50, but because the OOP max is $3,000, so you only pay an additional $2,250 to meet the $3,000 OOP max ($750 + $2,250 = $3,000).  Anthem pays the rest.  Now that you’ve satisfied the $3,000 OOP max, your cost for his office visits, prescriptions and any other covered services will be $0. 
    • You and your son have reached the $6,000 family OOP max.  Anthem will pay 100% of the cost of covered services for the remainder of the calendar year. 

    Number two – What happens if I have a doctor’s appointment or hospital visit after I reach the out-of-pocket maximum? 

    Once someone has met the individual annual out-of-pocket maximum of $3,000, your cost for covered services is $0.  If you haven’t, you’d pay the appropriate copay for office visits and prescription drugs, and 25% of hospital-related charges. 

    Number three - is the $750 deductible added to the out-of-pocket maximum? 

    The out-of-pocket maximum for an individual is $3,000: you can reach this $3,000 with any combination of copayments, deductible (the entire $750 counts toward the OOP max) and the 25% coinsurance. 

    Number four – What happens if the hospital or doctor’s office to bill me if I am over the $3000 or $6000 out-of-pocket max? 

    You can contact the Alliant Benefit Advocate team (844.365.4414) for assistance with your bill.  Please note, only covered services accrue toward the OOP max.  If the doctor orders a service that is not covered by the plan, you could be responsible for payment, and it won’t be included in your OOP max calculation. 

    Reminder and Info: Benefits Fair at Thousand Oaks ...
    Insurance Enrollment Form on Website
    VCDSA color logo 100Ventura County DSA Public E-Mail List

    To subscribe to the Ventura County DSA E-Mail list, please fill out the information below and select "Subscribe".