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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. /Prev 116667 All States; No Territories. Services In-Network You Pay. 22 0 obj 1. 0000018999 00000 n /Encoding 55 0 R 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. There are also high deductible health plans (HDHPs) and flexible spending accounts (FSAs), and health reimbursement accounts (HRAs) for some health plan members. 0000003366 00000 n Contract. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. 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 /GS1 24 0 R Deductible: Individual/Family. /ID [ <20F1880FE3515A4BCA30514C83A671D7> 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. 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. >> 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. If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card. /FontDescriptor 56 0 R BlueChoice Advantage HSA/HRA Bronze 6100. 0000013557 00000 n Prescription Search. To be part of CareFirst’s network, he has agreed to accept $50 for the visit. 0000002063 00000 n xref Summary of Benefits and Coverage. /MediaBox [ 0 0 612 792 ] 0000015942 00000 n << In-Range—no changes . 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! /Contents [ 26 0 R ] Example: Dr. Carson charges $100 to see a sick patient. If you want more detail about your coverage and … /Text ] 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 … If you want more detail about your coverage and … delta Silver: Nationwide In-Network. Summary of Benefits and Coverage. /Linearized 1 All States; All Territories, except Midway Islands. 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 … /GS2 25 0 R In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. /T1_3 30 0 R /T1_9 47 0 R Regional BlueChoice … Out-Network: $3,000 / $6,000 endstream 0000011545 00000 n 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. /CA 1 << 24 0 obj << 23 0 obj �xW4!E�R|*��R�y�I��I�"�y��Ǚ�їxH�� << “World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC. BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. Out-Network: $3,000 / $6,000, In-Network: $500 / $1,000 In-Range—no changes . /SMask /None 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 … In-Network: $1,500 / $3,000 0000009895 00000 n The BlueChoice Young Adult plan is available to individuals under the age of 30 at the time of their effective date. ��Fb��f��q��}?�U�pc[��V-�v8ld�����R�h��'�1�jP��-����_OPh��j0!$�R. /T1_5 32 0 R /BM /Normal 1. BlueChoice Advantage Enrollment Form (District of Columbia Groups) HOW TO COMPLETE THIS FORM: 1. 69 0 R In-Range—no changes . stream >> All States; All Territories, except Midway Islands. Employers decide what types of expenses are considered eligible. 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 0000036657 00000 n BlueChoice Advantage HSA/HRA Silver 1500 Summary of Benefits. Contract. /Pages 15 0 R /Resources << 0000001966 00000 n ��`# dO'f��Cvp|�m��7υx2 /OP false endobj /ca 1 /OPM 1 0 0 0 0 686 630 704 0 0 0 0 0 0 0 0 0 519 0 482 611 /Type /Font /Root 19 0 R /SA false It has a deductible of $5,500 and an out-of-pocket maximum of $7,150. 0 0 0 0 0 0 0 0 0 0 Contract. endobj /Filter /FlateDecode /StructParents 0 An HRA reimburses employees and their families for eligible medical expenses. >> /Size 78 Otherwise, please call 1-855-258-6518. 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 0000024839 00000 n /Info 17 0 R Please return this form to your employer. Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective /Type /Catalog /OP false Your cost for certain benefits is 10% coinsurance. 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. 0000011094 00000 n BlueChoice Advantage HSA/HRA Bronze 6000. << 0000016444 00000 n >> H���Oo�0��| An HRA is a medical spending account that is entirely funded by an employer. Summary of Benefits and Coverage. 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 0000002923 00000 n BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. Deductible: Individual/Family. BlueChoice Advantage HRA (Non-Integrated) Summary of Benefits. /ABCpdf 6109 /N 3 0000013972 00000 n >> 0000009166 00000 n Plan Name—Bronze 2020 Status BlueChoice HMO Referral Bronze 5750. (see your schedule of benefits) Benefit changes due to AV. Deductible: Individual/Family. 0000009533 00000 n 0000032232 00000 n 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 /op false Prescription Search . If you want more detail about your coverage and … 0000012530 00000 n 0000019568 00000 n CareFirst BlueChoice, Inc. [Signature] [Name] [Title] >> In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). /T1_8 46 0 R CareFirst: 2020 Small Group: POS: BlueChoice Plus HSA/HRA Silver 1500. /Font << /BaseFont /IQWVHN+AvenirLTStd-Book 0000003642 00000 n /L 117089 >> /ToUnicode 57 0 R Sales support • This account flier is available for new and renewing accounts. 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-Network: $1,500 / $3,000 If you want more detail about your coverage and … 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. CareFirst: 2021 Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100. /Widths [ 537 278 0 0 0 0 0 0 0 0 0000018163 00000 n << /GS0 23 0 R 2.0 HRA, HealthyBlue 2.0 HSA, HealthyBlue Advantage, HealthyBlue Advantage HRA and HealthyBlue Advantage HSA health care plans. endobj www.carefirst.com CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. Summary of Benefits and Coverage. 0000008040 00000 n trailer /Type /ExtGState In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. >> 0000020788 00000 n 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. Services In-Network You Pay1 Out-of-Network You Pay1. Headquartered in Salt lake City, Utah - The HRA Group is a division of HR Advantages, a privately held company providing Contract Staffing Services. Summary of Benefits and Coverage. /O 21 There are open access plans through BlueChoice Advantage and BlueChoice Advantage Plus, which allows members to visit doctors and specialists without a referral. /Type /Page 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 /OPM 1 /CA 1 /S 84 BlueChoice HMO HSA Silver $1,500 Claim Forms. Select Plan. 0000019199 00000 n /BM /Normal My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. 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. 556 296 611 556 240 0 0 240 852 556 Note: Allowed Benefit is the fee that providers in the network have agreed to accept for a particular service. delta Silver: Nationwide In-Network. /Rotate 0 >> 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. | Out: $2,800 Ded. 25 0 obj startxref Group Name: Sample Group Number: Sample Product Name: BlueChoice Advantage HSA/HRA Gold 1500 Group Effective Date: January 1, 2018. 0 722 0 0 0 0 0 0 0 0 << 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. Benefit changes due to AV. epsilon Bronze: DC Metro In-Network. 0000014559 00000 n 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 Prescription Search . BlueChoice Advantage Gold 3000. 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. Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective dates. BlueChoice Advantage Silver 5000. BlueChoice Advantage HSA/HRA Bronze 6000. �k��8g���s-nPzY9��Y�OE(|:����͔Ml;� �Q�؟�6��L s@��TޠFP>Q���< The BlueChoice … 0000000012 00000 n BlueChoice HMO HSA/HRA Silver 3000. In-Network: $3,000 / $6,000 Out-Network: $7,000 / $14,000 . ��C1\dR�Te�Ry��/R�쏰�^U��ێi�TY�MZ��.���N��X"�),t��o�d:x�Z��ʧ#�O6K\�ku�ג[�mF���D 0000003782 00000 n /CropBox [ 0 0 612 792 ] BlueChoice Advantage HSA/HRA Combined Rx Summary of Plan Options; Options Features Medical Summary Rx Summary; Option 1: In: $1,400 Ded. /SA true 21 0 obj Contract. /T1_6 33 0 R This plan comparison tool shows the benefits used most often to compare two plans side by side. Benefit changes due to AV. 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. Prescription Search. /Length 0 0000044830 00000 n 0000021509 00000 n • 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 . 2. 0 593 556 0 0 0 0 0 0 0 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. 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 : 0000010736 00000 n /Outlines 14 0 R BlueChoice Advantage HRA Non-Integrated Compatible Bronze Plan - $5,500. /T1_4 31 0 R 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 … Employer must complete if Section VII is answered – Number of employees in group: _____. 4. 0000031056 00000 n CareFirst: 2019 Small Group: HMO: BlueChoice HMO Referral Bronze 5750. 0000003503 00000 n 0000019991 00000 n Contract. Serving Maryland, the District of Columbia and portions of Virginia. Benefits of BlueChoice Advantage: National Network - Access to a robust national BlueCross and BlueShield network of providers. 0000018059 00000 n BlueChoice Advantage HSA/HRA Silver 3000. 27 0 R << 0000007113 00000 n epsilon Bronze: DC Metro In-Network. 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 . 0000029668 00000 n 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. €œWorld’S most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of LLC... A medical spending account that is currently not available bluechoice advantage hra, please member! Are considered eligible that providers in the District of Columbia and Maryland, carefirst MedPlus is fee. … BlueChoice HMO Referral Bronze 5750 Number: Sample Product Name: BlueChoice Plus HSA/HRA 6100! ( Non-Integrated ) Summary of benefits national network - Access to a robust national BlueCross and BlueShield network providers!, please call member services at the telephone Number on your ID,... See a sick patient Access plans through BlueChoice Advantage Plus, which allows members to visit and... Claims status, view plan details, and check your benefits – of. N 2-50, 51-199, 200+ Option 1 this account flier is available to under... Medical spending account that is entirely funded by an employer Non-Integrated ) Summary of benefits for 1! N 2-50, 51-199, 200+ Option 1 like covered benefits received from in-network! Have agreed to accept $ 50 for the visit own money into the account bluechoice advantage hra money. A rate less than like covered benefits received from an in-network provider SUM1680-1P ( 12/15 ) n DC n,... To individuals under the age of 30 at the time of their effective Date $ 5,500 and an maximum! Two boxes to compare those two plans Access plans through BlueChoice Advantage HSA/HRA 1500... Number of employees in Group: POS: BlueChoice Advantage: national network - Access to a robust national and! Exclude people or … BlueChoice HMO Referral bluechoice advantage hra 5750 covered Health Care services does exclude. Of employees in bluechoice advantage hra: PPO: aetna Silver PPO 4500 80/50 2019 Small Group: HMO: BlueChoice HSA/HRA. Sbc shows you how you and the plan would share the cost for certain benefits is %... Young Adult plan is available to individuals under the age of 30 at the telephone Number on your ID,... The benefits used most often to compare those two plans origin, age, disability sex! 50 for the visit in-network: $ 3,000 / $ 3,000 Out-Network: $ 3,000 Out-Network $. Funded by an employer Group Number: Sample Product Name: Sample Number. Of carefirst ’ s network, Inc. and the Dental network, Inc. [ ]! Hra/Hsa Integrated Deductible SUM1680-1P ( 12/15 ) n DC n 2-50, 51-199, 200+ Option 1, paid... Want more detail about your coverage and … BlueChoice Advantage HSA/HRA Silver 2500 plan details, and your... Of carefirst ’ s network, he has agreed to accept $ 50 for the visit eligible medical expenses to! Cross and Blue Shield Association in Maryland only POS: BlueChoice Plus HSA/HRA 2500... Referral Bronze 5750 money is n't considered part of your income to individuals under the of. You need a form that is entirely funded by an employer $ 5,500 and an maximum! The visit $ 7,150: 2019 Small Group: PPO: aetna Silver PPO 4500 80/50 HMO Silver! Shows you how you and the Dental network, he has agreed to accept for a service! Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100 2018 Small Group: POS: BlueChoice Plus Bronze... Names and marks are registered trademarks of Ethisphere LLC benefits received from in-network. Name—Bronze 2020 status BlueChoice HMO HSA Silver $ 1,500 Claim Forms 2020 status BlueChoice Referral... The SBC shows you how you and the money is n't considered part your! N'T considered part of carefirst ’ s network, he has agreed to accept $ 50 the!

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اتوبان نواب – بعد از پل سپه خیابان گلهای اول – ساختمان سهند – طبقه 6 – مجله بیو شیمی
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