2017 SHBP
MEDICAL BENEFITS
SHBP
State Health Benefit Plan
A Division of the Georgia Department of Community Health
HRA GOLD
In-network
DEDUCTIBLE
Administered by
HRA SILVER
Out-of-network
In-network
HRA BRONZE
Out-of-network
In-network
HMO1
Out-of-network
In-network
(Family deductible can be satisfied by any combination of family members but an individual would never satisfy more than their own individual deductible.)
YOU
$1,500
$3,000
$2,000
$4,000
$2,500
$5,000
$1,300
YOU + SPOUSE
$2,250
$4,500
$3,000
$6,000
$3,750
$7,500
$1,950
YOU + CHILD(REN)
$2,250
$4,500
$3,000
$6,000
$3,750
$7,500
$1,950
YOU + FAMILY
$3,000
$6,000
$4,000
$8,000
$5,000
$10,000
$2,600
C0-INSURANCE
(Applies after deductible is met.)
PLAN PAYS
85% after deductible
60% after deductible
80% after deductible
60% after deductible
75% after deductible
60% after deductible
80% after deductible
MEMBER PAYS
15% after deductible
40% after deductible
20% after deductible
40% after deductible
25% after deductible
40% after deductible
20% after deductible
OUT-OF-POCKET MAXIMUM2
(Family out-of-pocket can be satisfied by any combination of family members, but an individual would never satisfy more than their own individual out-of-pocket.)
YOU
$4,000
$8,000
$5,000
$10,000
$6,000
$12,000
$4,000
YOU + SPOUSE
$6,000
$12,000
$7,500
$15,000
$9,000
$18,000
$6,500
YOU + CHILD(REN)
$6,000
$12,000
$7,500
$15,000
$9,000
$18,000
$6,500
YOU + FAMILY
$8,000
$16,000
$10,000
$20,000
$12,000
$24,000
$9,000
GOLD BASE
CONTRIBUTION
SILVER BASE
CONTRIBUTION
HMO3
(Silver Base + Completion of all
2017 well-being incentive actions)
BRONZE BASE
CONTRIBUTION
BRONZE TOTAL
(Gold Base + Completion of all
2017 well-being incentive actions)
(Bronze Base + Completion of all
2017 well-being incentive actions)
(Completion of all 2017
well-being incentive actions)
YOU
$400
880
$200
680
$100
580
480
YOU + SPOUSE
$600
1,560
$300
1,260
$150
1,110
960
YOU + CHILD(REN)
$600
1,080
$300
780
$150
630
480
YOU + FAMILY
$800
1,760
$400
1,360
$200
1,160
960
GOLD TOTAL
1. Out-of-network coverage is not available for the HMO plan.
2. Pharmacy costs count toward your out-of-pocket maximum.
3. The MyIncentive Account is a standalone account offered alongside the HMO plan where you can earn well-being incentive credits by participating in the Be Well
SHBP well-being program (administered by Healthways®). The well-being incentive credits earned can be used to pay for eligible medical and pharmacy expenses.
SILVER TOTAL
This is a high-level summary of benefits. It does not describe all benefits and does not describe exclusions and limitations. The plan documents posted on
http://dch.georgia.gov/shbp-plan-documents include the full details. Dollar amounts, visit limitations, medical co-pays (HMO), co-insurance, deductible and
out-of-pocket limits are based on January 1 – December 31, 2017 plan year. All covered medical services are subject to deductible except preventive care,
LiveHealth Online visits, ABA therapy, and hearing aids. Note: Medical co-pays (HMO) do not count toward the deductible but do count toward the out-of-pocket
maximum. The plan pays a percentage of the maximum allowed amount for covered services performed by out-of-network providers.
2017 SHBP
MEDICAL BENEFITS
SHBP
State Health Benefit Plan
A Division of the Georgia Department of Community Health
HRA GOLD
MEDICAL
Preventive care2
Administered by
HRA SILVER
In-network
Out-of-network
% PAID BY PLAN
100%
HRA BRONZE
In-network
Out-of-network
you could be balance billed
% PAID BY PLAN
Not covered
100%
% PAID BY PLAN;
HMO1
In-network
Out-of-network
you could be balance billed
% PAID BY PLAN
you could be balance billed
% PAID BY PLAN
Not covered
100%
Not covered
100%
% PAID BY PLAN;
% PAID BY PLAN;
In-network
Physician Office Services3 (illness/injury)
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $35 co-pay
Specialist Office Services (illness/injury)
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $45 co-pay
15% co-insurance applies
20% co-insurance applies
25% co-insurance applies
$35 co-pay
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $45 co-pay
LiveHealth Online
Chiropractic visit
(20 visits per Plan year)
Eye exam — routine
(limited to one exam
every 24 months; not subject to deductible)
100%
Not covered
100%
Not covered
100%
Not covered
100%
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after
deductible
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $35 co-pay
Physical, speech, cardiac, occupational,
pulmonary therapy (40 visits per therapy per
plan year)
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $25 co-pay
Emergency Room Care —Hospital
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $150 co-pay
Urgent care visit/retail health clinic
Co-insurance after deductible
Co-insurance after deductible
Co-insurance after deductible
100% after $35 co-pay
Hospital services (inpatient/outpatient)
Maternity care
Physician routine prenatal care,
delivery and postnatal
Outpatient rehabilitation therapy
For more benefit information,
visit bcbsga.com/shbp or
call toll free 855-641-4862.
1. Out-of-network coverage is not available for the HMO plan.
2. Services must be properly coded as preventive care under the Patient Protection and Affordable Care Act and provided by an in-network doctor.
3. Primary Care is defined as Family Practice, General Practice, Internal Medicine, Pediatrics and OB/GYN.
This is a high-level summary of benefits. It does not describe all benefits and does not describe exclusions and limitations. The plan documents posted on
http://dch.georgia.gov/shbp-plan-documents include the full details. Dollar amounts, visit limitations, medical co-pays (HMO), co-insurance, deductible and
out-of-pocket limits are based on January 1 – December 31, 2017 plan year. All covered medical services are subject to deductible except preventive care,
LiveHealth Online visits, ABA therapy, and hearing aids. Note: Medical co-pays (HMO) do not count toward the deductible but do count toward the out-of-pocket
maximum. The plan pays a percentage of the maximum allowed amount for covered services performed by out-of-network providers.