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Plan Coverage Options: A, B, C, D, HDHP, HMO
 
Option A

Medical Care Benefits – Preferred Provider Organization (PPO)
Call toll-free:
Blue Cross Blue Shield of Minnesota: 800-793-6922
Members receive greater benefits if they access care through a physician in the network and use network providers for health services. The member does not have to select a primary care physician and can self-refer to any specialist physician in the network. If non-network providers are used, benefits are still payable but at a lower percentage and after a deductible is satisfied.
 
Network Benefits Member Pays:
Non-Network Benefits* Member Pays:
Annual Deductible $0 individual
$0 family unit ***		 $400 individual
$800 family unit***
Coinsurance 10% 30%
Annual coinsurance limit** $500 individual
$1,000 family unit***		 $1,750 individual
$3,500 family unit***
Physician's office visits $20 copay 30% after deductible

Routine Care (Adults, Children, Well Baby Care)

 $20 copay 100%
Inpatient and Outpatient Hospital Care 10% 30% after deductible
Hospital Emergency Room for life-threatening emergency $100 copay (waived if admitted) $100 copay (waived if admitted)
Lifetime maximum on all benefits paid by the CHP $2.5 million $2.5 million
* Eligible charges are based on an allowed amount. You are responsible for amounts exceeding the allowed amount.
** Not applicable to copays or deductibles.
*** "Family unit" shall mean a member and that member's enrolled dependents.
 
 
Option B

Medical Care Benefits – Preferred Provider Organization (PPO)
Call toll-free:
Blue Cross Blue Shield of Minnesota: 800-793-6922
If an employer and/or member has chosen this managed care option, members receive greater benefits if they access care through a physician in the network, use network providers for health services, and satisfy a deductible. If non-network providers are used, benefits are still payable but at a lower percentage and after a higher deductible is satisfied.
 
Network Benefits Member Pays:
Non-Network Benefits* Member Pays:
Annual Deductible $300 individual
$600 family unit ***		 $600 individual
$1,200 family unit***
Coinsurance 15% 40%
Annual coinsurance limit** $1,500 individual
$3,000 family unit***		 $4,000 individual
$8,000 family unit***
Physician's office visits $20 copay 40% after deductible

Routine Care (Adults, Children, Well Baby Care)

 $20 copay 100%
Inpatient and Outpatient Hospital Care 15% after deductible 40% after deductible
Hospital Emergency Room for life-threatening emergency $100 copay (waived if admitted) $100 copay (waived if admitted)
Lifetime maximum on all benefits paid by the CHP $2.5 million $2.5 million
* Eligible charges are based on an allowed amount. You are responsible for amounts exceeding the allowed amount.
** Not applicable to copays or deductibles.
*** "Family unit" shall mean a member and that member's enrolled dependents.
 
 
Option C

Medical Care Benefits – Preferred Provider Organization (PPO)
Call toll-free:
Blue Cross Blue Shield of Minnesota: 800-793-6922
If an employer and/or member has chosen this managed care option, members receive greater benefits if they access care through a physician in the network, use network providers for health services, and satisfy a deductible. If non-network providers are used, benefits are still payable but at a lower percentage and after a higher deductible is satisfied.
 
Network Benefits Member Pays:
Non-Network Benefits* Member Pays:
Annual Deductible $500 individual
$1,000 family unit ***		 $1,000 individual
$2,000 family unit***
Coinsurance 20% 40%
Annual coinsurance limit** $2,000 individual
$4,000 family unit***		 $5,000 individual
$10,000 family unit***
Physician's office visits $25 copay 40% after deductible

Routine Care (Adults, Children, Well Baby Care)

 $25 copay 100%
Inpatient and Outpatient Hospital Care 20% after deductible 40% after deductible
Hospital Emergency Room for life-threatening emergency $100 copay (waived if admitted) $100 copay (waived if admitted)
Lifetime maximum on all benefits paid by the CHP $2.5 million $2.5 million
* Eligible charges are based on an allowed amount. You are responsible for amounts exceeding the allowed amount.
** Not applicable to copays or deductibles.
*** "Family unit" shall mean a member and that member's enrolled dependents.
 
 
Option D

Medical Care Benefits – Preferred Provider Organization (PPO)
Call toll-free:
Blue Cross Blue Shield of Minnesota: 800-793-6922
If an employer and/or member has chosen this managed care option, members receive greater benefits if they access care through a physician in the network, use network providers for health services, and satisfy a deductible. If non-network providers are used, benefits are still payable but at a lower percentage and after a higher deductible is satisfied.
 
Network Benefits Member Pays:
Non-Network Benefits* Member Pays:
Annual Deductible $1,000 individual
$2,000 family unit ***		 $2,000 individual
$4,000 family unit***
Coinsurance 20% 40%
Annual coinsurance limit** $2,500 individual
$5,000 family unit***		 $7,500 individual
$15,000 family unit***
Physician's office visits $30 copay 40% after deductible

Routine Care (Adults, Children, Well Baby Care)

 $30 copay 100%
Inpatient and Outpatient Hospital Care 20% after deductible 40% after deductible
Hospital Emergency Room for life-threatening emergency $100 copay (waived if admitted) $100 copay (waived if admitted)
Lifetime maximum on all benefits paid by the CHP $2.5 million $2.5 million
* Eligible charges are based on an allowed amount. You are responsible for amounts exceeding the allowed amount.
** Not applicable to copays or deductibles.
*** "Family unit" shall mean a member and that member's enrolled dependents.
 
 
Option HDHP

HSA-Compatible High Deductible Health Plan (HDHP)
Administered by Blue Cross Blue Shield of Minnesota: 800-793-6922
 
Option HDHP is an HSA-compatible HDHP first introduced in 2005. The medical, prescription drug, and mental health/substance abuse benefit information listed below applies only to CHP Option HDHP.
 
Network Benefits Member Pays:
Non-Network Benefits Member Pays:
Self-only Deductible $2,750 $8,250
Family Deductible $5,500 $16,500
Coinsurance 0% 20%
Self-only Coinsurance Maximum $0 $5,000
Family Coinsurance Maximum $0 $15,000

Self-only Out-of-Pocket Maximum

 $2,750 $13,250
Family Out-of-Pocket Maximum $5,500 $31,500

Routine Checkups

0% 20% after deductible
Medical Care (office visits, inpatient & outpatient hospitalizations, lab, x-ray, supplies, etc.) 0% after deductible 20% after deductible
Emergency Room Care 0% after deductible 0% after deductible
Mental Health & Substance Abuse Care (Benefits administered by BCBS—plan limits still apply) 0% after deductible 20% after deductible
Lifetime maximum on all benefits paid by the CHP $2.5 million $2.5 million
 
Option HMO - California

Administered by CIGNA HealthCare of California: 800-CIGNA24 (244-6224)
 
Note: The medical benefit information listed below applies only for Option HMO in Southern California. To find out if an HMO option is available in your area, please contact Concordia Plan Services toll-free: 888-927-7526
 
Network Benefits Member Pays:
Non-Network Benefits Member Pays:
Self-only Deductible $0 100%
Family Deductible $0 100%
Coinsurance 0% 100%
Self-only Coinsurance Maximum $0 100%
Family Coinsurance Maximum $0 100%

Self-only Out-of-Pocket Maximum

 $1,500 100%
Family Out-of-Pocket Maximum $4,500 100%

Routine Checkups
Primary Care Physician
Specilaist Office Visit


$15 copay
$15 copay		 100%
Inpatient & Outpatient Hospitalizations $350 copay 100%
Emergency Room Care (life threatening emergency) %75 copay (waived if admitted) 100%
Urgent Care Facility $75 copay 100%
Lifetime maximum on all benefits paid by the CHP Unlimited Not Applicable
 
 
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