CHESAPEAKE PUBLIC SCHOOLS
HEALTH PLAN COMPARISON
October 1, 2017 - September 30, 2018
05/24/17
1 OF 3
HEALTHKEEPERS POS/HEALTHKEEPERS POS OPEN ACCESS/KEYCARE PREFERRED PROVIDER ORGANIZATION (PPO)
HEALTHKEEPERS POS OPEN
HEALTHKEEPERS POS
ACCESS
KEYCARE PPO
REFERRAL BY PCP REQUIRED
NO REFERRAL REQUIRED
IN-NETWORK: WHEN SERVICES ARE RECEIVED BY PROVIDERS WHO ARE PART OF ANTHEM'S NETWORKS
YOU PAY
YOU PAY
YOU PAY
Deductible
No Deductible
Includes Medical and Prescription Drug
copays/coinsurance amounts you pay
No Deductible
Out-of-Pocket Maximum (Calendar Year)
Office Visit/Urgent Care/Home Visits/In-office
Surgery
Online visits
(LiveHealth Online.com)
Spinal Manipulations and other manual medical
intervention visits (30 visit limit)
$3,500 individual
$7,000 family
No Deductible
$3,500 individual
$7,000 family
$3,500 individual
$7,000 family
$20 PCP (Primary Care Physician)
$40 Specialist
$20 PCP (Primary Care Physician)
$40 Specialist
$20 PCP (Primary Care Physician)
$40 Specialist
$10
$10
$10
$25
$25
$20 PCP
$40 Specialist
Provider Visits
Labs, Diagnostic X-rays, Other Outpatient Diagnostic Tests
Diagnostic X-rays*
Lab Work*
Advanced diagnostic imaging services (ex: MRI, MRA,
CT Scan, PET Scan)
$20/PCP*
$40/Specialist*
$20/PCP*
$40/Specialist*
$20/PCP*
$40/Specialist*
$20/PCP*
$40/Specialist*
20%
20%
20%
20%
$40 at provider
20% home services
20%
$40 at provider
20% home services
20%
$20/$40** + 20%
$20/$40** + 20%
20%
20%
20%
Other Outpatient Services
Dialysis
Infusion
Shots & Therapeutic injections
20%
CHESAPEAKE PUBLIC SCHOOLS
HEALTH PLAN COMPARISON
October 1, 2017 - September 30, 2018
05/24/17
2 OF 3
HEALTHKEEPERS POS/HEALTHKEEPERS POS OPEN ACCESS/KEYCARE PREFERRED PROVIDER ORGANIZATION (PPO)
HEALTHKEEPERS POS OPEN
HEALTHKEEPERS POS
ACCESS
KEYCARE PPO
REFERRAL BY PCP REQUIRED
NO REFERRAL REQUIRED
IN-NETWORK: WHEN SERVICES ARE RECEIVED BY PROVIDERS WHO ARE PART OF ANTHEM'S NETWORKS
Chemotherapy (not oral), radiation, cardiac and
respiratory therapy
$40
Home Health Care (100 visits)
Routine pre- and postnatal care (excludes inpatient
stay)
Diagnostic Test/Non-stress test and other fetal
monitoring/Ultrasounds
Physical/Occupational Therapy in office or
outpatient facility (30 visits combined)
Speech Therapy in office or outpatient facility (30
visit limit)
Durable Medical Equipment
Ambulance
Surgery: Facility and Physician charges
$40
20%
20%
20%
20%
$200
$200
$200
$40 per visit
$40 per visit
20%
$10
$10
$10
$10
$10
$10
20%
$150
20%
$150
20%
$150
$250/visit
$250/visit
$200 + 20%
Care at Home
Maternity
Other
Outpatient Visits: Hospital or Facility
Inpatient Stays: Hospital or Facility
Semi-private room, intensive care or similar unit
Physician, nursing, other medical professional
services including anesthesia, surgical and delivery
services
Skilled nursing facility (100 days per admission)
$300/day up to $1500
$300/day up to $1500
$400 + 20%
No charge
No charge
20%
20%
20%
20%
Emergency Room and Physician Charges
$200
$200
$200 + 20%
Emergency Care
CHESAPEAKE PUBLIC SCHOOLS
HEALTH PLAN COMPARISON
October 1, 2017 - September 30, 2018
05/24/17
3 OF 3
HEALTHKEEPERS POS/HEALTHKEEPERS POS OPEN ACCESS/KEYCARE PREFERRED PROVIDER ORGANIZATION (PPO)
HEALTHKEEPERS POS OPEN
HEALTHKEEPERS POS
ACCESS
KEYCARE PPO
REFERRAL BY PCP REQUIRED
NO REFERRAL REQUIRED
IN-NETWORK: WHEN SERVICES ARE RECEIVED BY PROVIDERS WHO ARE PART OF ANTHEM'S NETWORKS
Mental Health/Substance Abuse
Office Visit
Outpatient Facility based treatment (includes Partial
Day programs)
$20
$20
$20
No charge
No charge
No charge
OUT-OF-NETWORK: WHEN SERVICES ARE RECEIVED BY PROVIDERS WHO ARE NOT PART OF ANTHEM'S NETWORKS
Deductible-Calendar Year
Out-of-pocket maximum-Calendar Year
Coinsurance - applies to all covered services
(balance billing will occur)
YOU PAY
$750 individual
$1,500 family
$5,000 individual
$10,000 family
YOU PAY
$750 individual
$1,500 family
$5,000 individual
$10,000 family
YOU PAY
$500 individual
$1,000 family
$5,500 individual
$11,000 family
30%
30%
30%
*A copay does not apply when these services are provided by the same provider on the same day as the office visit.
**You will pay an additional $20 or $40 office visit copayment depending on the type of provider who treats you.