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ANTHEM PPO GOLD $1000

Policy Info

Product Type

Product Name to Display

Carrier / Provider *

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Plan Name *

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Internal Plan Name/ID

Group Number

Subgroup Number

This is a High Deductible Health Plan. Employees enrolled in this plan may also be eligible to enroll in an HSA and Limited Purpose FSA.

Level

Effective Start Date *

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Effective End Date *

Effective end date is required

Policy Anniversary Month *

Policy anniversary month is required

Coverage

Number of benefit summary columns

Column 1 Title *

Required

Column 2 Title *

Required

Column 3 Title *

Required

Coverage Basics

Add / Remove Fields

@[[i.id]]

Required

Physician / Medical Services

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@[[i.id]]

Required

Hospital Services

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@[[i.id]]

Required

Emergency Care Services

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@[[i.id]]

Required

Extended Care Services

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@[[i.id]]

Required

Additional Services

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@[[i.id]]

Required

Prescription Drugs

Add / Remove Fields

@[[i.id]]

Required

Additional Coverage / Notes

Rate Options

Rate type *

Rates based on

Tobacco

Location

At Which Age Should New Enrollments Be Rated *

Required

Age Band Changes Become Effective on *

Required

Spouse Rate Based on Employee Age

Child Rate Option *

Required

Max Number of Children Charged

Required

Children

Children Are Considered Adults at a Certain Age

Age Child is Considered an Adult *

Required and must be between 0 and 100

Years

Coverage tiers *

@[[getCoverageTierGroupNameByID(tierGroup.id)]]
- @[[item.name]]

Required

Tobacco rate option *

Required

Tobacco surcharge fee *

Required

Max # of children covered under +child(ren) tier

Invalid

Children

Location Based on *

Required

Monthly Rates

Coverage tiers

Rates Non-tobacco Tobacco

@[[t.name]]

Missing or invalid

Monthly Rates

Location Title *

Required

Country *

Required

State/Province

County

City

Zip Code

Work Locations

Required

Monthly Rates

Coverage tiers

Rates Non-tobacco Tobacco

@[[t.name]]

Missing or invalid

Enter 21 year old rate

Missing or invalid

From Age To Age

Age Range for First Bracket

Last Bracket Age+

No rates have been defined!

Age

Rates

0-14 @[[n]] 64+

Missing or invalid

Age

Rates

0-@[[manual_first_bracket_last_age]] @[[n]] @[[(manual_last_age_bracket)]]+

Missing or invalid

Child

Missing or invalid

Contribution Options

Contribution Amounts are the Same for All Employees

Monthly Contribution

Contribution Strategy*

Contribution strategy is required

Coverage Tiers *

@[[getCoverageTierGroupNameByID(tierGroup.id)]]
- @[[item.name]]

Coverage tier is required

@[[t.name]]

Rule

Missing or invalid

Value

Missing or invalid

Value

Missing or invalid

Up to Max

Base Plan *

Missing or invalid

Flat Company Contribution

Rule

Missing or invalid

Value

Missing or invalid

Up to Max

Contingency Type *

Missing or invalid

Product Type *

Missing or invalid

Employee Tax Determination*

Missing or invalid

Highly compensated employees are not eligible for pre-tax deductions

If checked, any employee who is marked as Highly Compensated on the Employment tab of their profile will be assigned post tax deductions.

Enrollment Options

Require Employees to Enroll in Plan

Display Employer Contribution During Enrollment

Capture Primary Care Physician During Enrollment

The PCP fields captured during enrollment are PCP ID, PCP Name and PCP Location

Carrier Forms

Employee demographic and enrollment information will be mapped to forms that are attached to this plan. Employees will be required to view completed forms for accuracy before they can submit their enrollment.

Carrier Forms

Add Carrier Form

Small Business Enrollment Form

Enter the Plan Name That Should Be Listed on the Form*

You must input a plan name.

Enter the Policy / Group Number*

You must provide the Group / Policy Number.

Enter the Policy / Subgroup Number

Disclosures

Disclosures can be added to support scenarios where a carrier requires specific communication/text to be disclosed to employees after they make an enrollment selection. Disclosures will be presented to employees during enrollment, and they will be required to acknowledge that they have read the disclosure text before proceeding to the next step.

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Active Inactive

Disclosures

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Disclosure Name	Actions	Status
Medical Plan A Disclosure	\|	Active

Form	Carrier/Provider	State	Form #	Products	Year	Add to Plan

Plan Riders

A rider is an insurance policy provision that adds benefits to, or amends the terms of, a basic insurance policy. Riders provide insured parties with options such as additional coverage, or they may even restrict or limit coverage. Note: Rider costs must be entered as the monthly rate.

Rider Name*

Required

Description

Enrollment is Required

Include Cost in Contributions

Cost Based on Tobacco Use

Cost Structure*

Coverage Tiers*

Coverage Tier Rates

Employee

Missing or invalid

Employee + Spouse

Missing or invalid

Employee + Child(ren)

Missing or invalid

Family

Missing or invalid

Resources

Optional plan resources. Employees can access this information via the plan details. link during enrollment, and throughout the year from their benefits portal.

Website Links

Anthem Website

Find a Doctor

Contacts

Customer Service
888-777-7777

Documents

Gold $1000 PPO SBC

Plan Description

This is a PPO plan with Anthem. PPO plans provide richer benefits at a higher cost, and also allow subscribers to visit a larger network of doctors and facilities.

Payroll Deduction Codes

Deduction Frequency Overrides

Deduction Codes Are the Same for All Pay Groups

Employee Pre-Tax Code

Employee Post Tax Code

Employer Code

Pay Group

Employee Pre-Tax Code

Employee Post Tax Code

Employer Code

Optional override settings for benefit deductions to accommodate scenarios where employee pay and deduction frequencies are different. For example, employees are paid bi-weekly (26 pays), but benefit deductions are only taken out of 24 pay dates. Per pay costs will be calculated accordingly.

Summary

Enrolled

2097

Eligible

Policy Info

Product Type

Medical

Provider / Carrier

Anthem Blue Cross

Plan Name

ANTHEM PPO GOLD $1000

Internal Plan Name/ID

Med Gold 1000

Group #

Cf-12345679

Plan Type

PPO

High Deductible Health Plan

Level

gold

Effective Start Date

12/01/2019

Effective End Date

11/30/2020

Eligibility

Domestic Partners are Eligible for Enrollment

Age Children Become Ineligible

26 years old

Age Students Become Ineligible

26 years old

Age Employees Become Ineligible

Age Spouses Become Ineligible

Plan Eligibility

Same for All Eligible Employees

New Hire Waiting Period

Same for All Eligible Employees

Waiting Period: 60 Day(s) 1st of month after

Termination Rule

End Coverage: End of Termination Month

Newly Eligible Rules

Same for All Eligible Employees

Waiting Period: 0 Day(s) 1st of month after

Rehire Rules

Same for All Eligible Employees

Waiting Period: 30 Day(s) 1st of month after

Rehire within: 90 Day(s)

Coverage

	In Network	Out of Network
Coverage
Annual Individual Deductible	1000	2000
Annual Family Deductible	2000	4000
Coinsurance	80%	80%
Physician/Medical Services
Preventive Services	0%	0%
Primary Care Physician	$25 copay	80%
Specialist	$45 copay	80%
Hospital Services
Inpatient Hospital	20%	60%
Outpatient Hospital	20%	60%
Emergency Services
Emergency Room	$100 copay	$100 copay
Urgent Care	$30 copay	60%
Extended Care Services
Home Health Care	$100 copay	$100 copay
Hospice Services	$30 copay	60%
Additional Services
Prescription Drugs
Prescription Deductible	$0	$0
Retail Supply Limit	60 Days	30 Days
Retail Generic Drugs	$0 copay	80%
Retail Preferred Brand Drugs	$25 copay	80%
Retail Specialty Drugs	$75 copay	80%

Additional Coverage / Notes

Rates

Rate type

Composite

Rates based on

Coverage Tiers

Standard Composite 2 (+children)

Max # of children covered under +child(ren) tier

3 child(ren)

Coverage tiers

Rates

Employee

Employee + Spouse

Employee + Child(ren)

Family

Contributions

Contribution amounts are the same for all employees

Yes

Contribution Strategy

By Coverage Tier

Coverage Tiers

Standard Composite 2 (+children)

Employee

Company Flat Percentage: 50.00 %

Employee + Spouse

Company Additional Percentage: 25.00 %

Employee + Child(ren)

Company Additional Percentage: 25.00 %

Family

Company Additional Percentage: 25.00 %

Employee Tax Determination

Pre Tax

Highly Compensated Employees Are Not Eligible For Pre-tax Deductions

Additional Settings

Enrollment Options

Require employees to enroll in plan

Yes

Display employer contribution during enrollment

Yes

Capture PCP during enrollment

Resources

Website Links

Links

Contacts

Customer Service

888-777-7777

Documents

Gold $1000 PPO SBC

Plan Description

This is a PPO plan with Anthem. PPO plans provide richer benefits at a higher cost, and also allow subscribers to visit a larger network of doctors and facilities.

Privacy & Terms

Have questions? Call (888) 320 4456

Policy Info

Eligibility Options

Eligibility Rules

Plan Eligibility

New Hire Waiting Period

Termination Rule

Newly Eligible Rules

Rehire Rules

Plan Bundling & Dependencies

Contingencies

Restrictions

Eligibility Underwriting Questions

Coverage

Coverage Basics

Physician / Medical Services

Hospital Services

Emergency Care Services

Extended Care Services

Additional Services

Prescription Drugs

Rate Options

Monthly Rates

Monthly Rates

Monthly Rates

Contribution Options

Monthly Contribution

Contribution Schedule #1

Enrollment Options

Carrier Forms

Disclosures

Plan Riders

New enrollments age rules must be same in different riders

Age band change rules must be same in different riders

Delete Rider

Resources

Website Links

Delete Website Link

Contacts

Delete Contact

Documents

Delete Document

Plan Description

Payroll Deduction Codes

Deduction Frequency Overrides

Summary

Plan Eligibility

New Hire Waiting Period

Termination Rule

Newly Eligible Rules

Rehire Rules

Enrollment Options

Website Links

Contacts

Documents

Plan Description

Activate Plan

Deactivate Plan