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2018 Anthem PPO HDHP FAQ and Resources

Frequently Asked Questions (FAQ)

The following questions and answers will help you better understand the Anthem PPO HDHP (High Deductible Health Plan).

A. Comprehensive Coverage
  1. Are the types of services covered under this plan different than other IU medical plans?

    No. The plan covers medical, prescription, behavioral health, and transplant services the same as other IU employee medical plans.  The difference is primarily in the deductibles and copays.

  2. Are pre-existing conditions covered?

    Yes.  IU-sponsored employee medical plans do not have any pre-existing condition limits on new enrollees or when an employee moves from one IU plan to another.

  3. Is there any waiting period before certain services are covered?

    No.

  4. What if I enroll in the plan this year and don’t like it?

    Each year during Open Enrollment you may choose to move to any of the available IU medical plans.

    If you were enrolled in the HSA with your Anthem PPO HDHP enrollment, and you switch to the Anthem PPO $500 Deductible Plan then any of your unused contributions in your HSA will remain in your account to use for health expenses, but you will not be eligible to receive the IU contribution in the next year and you cannot make payroll contributions of your own. When you are no longer enrolled in the HSA, you will then be responsible for the account maintenance fees on the HSA. See Fee Schedule (PDF) for details.

    If you change your enrollment to the IU Health HDHP, you will be able to remain enrolled in the HSA.

B. Deductibles and Out-of-Pocket Maximums
  1. What are the deductibles and out-of-pocket maximums for 2018?

    For employee-only coverage, the deductible is $1,350 and the out-of-pocket maximum is $2,700. When one or more family members are covered the deductible is $2,700 and the out-of-pocket maximum is $5,400. There are separate deductibles and maximums for out-of-network services which are double the in-network amounts.

  2. How does the deductible work in this plan?  I’ve read that it is different than the Anthem PPO $500 Deductible plan.

    Yes, it is different in two ways.

    1. In an HDHP, the individual deductible only applies to an employee enrolled in employee-only coverage. When you enroll one or more family members, you have one family deductible.  Deductibles paid by any of the family members are totaled as one sum. No family member receives benefits until the family deductible is met. This is in contrast to plans which have separate, individual deductibles for each family member.
    2. The deductible does not apply to preventive care, including medical services and prescriptions; it does apply to all other medical services, non-preventive prescriptions, and behavioral health.
  3. Since prescription drugs are subject to the deductible, how can I find out what I will pay for my prescriptions before the deductible is met?

    Go to www.caremark.com and log in to view your prescription history or check with your pharmacy to find the full cost of the prescription you will pay until the deductible is met.

  4. If I enroll my spouse, does each of us have an individual or family deductible?

    The IRS defines “family” coverage as any coverage that includes one or more family members. An employee and spouse together have one family deductible. The medical costs of both are combined under this one $2,700 deductible. For example, if the employee has $2,000 in claims and the spouse has $700, the deductible is met. Neither spouse has benefits paid until the $2,700 is met either by one or both combined.

  5. After I have met the deductible, what is the coinsurance in this plan?

    Once the deductible is met, there is a 20% in-network coinsurance on most services including medical, prescription, and behavioral health services.  The out-of-network coinsurance is generally 40%.

  6. Are there different coinsurance costs for generic and brand drugs?

    No.  There is 20% coinsurance when network pharmacies are used.  Because brand drugs are generally higher in cost, the 20% coinsurance results in a higher coinsurance for higher cost drugs.

  7. How does the out-of-pocket maximum work?

    The IRS defines “family” coverage as any coverage that includes one or more family members. The individual out-of-pocket maximum only applies to an employee enrolled in employee-only coverage.  When you enroll one or more family members, the lower individual out-of-pocket maximum does not apply to any family member, only the family deductible.  All expenses for covered services paid by any family member are totaled to one family out-of-pocket maximum.  All members have to pay coinsurance costs until the family out-of-pocket maximum is met, then there is no coinsurance cost for any family member.

  8. What services does the deductible apply to?

    The deductible does not apply to non-covered services nor to preventive care, which includes preventive medical services and preventive prescriptions. The deductible does apply to all other medical services, non-preventive prescriptions, and behavioral health. See the list of prescriptions that are considered preventive (PDF). Also, see Preventive Medical Services (PDF) for examples of services that are considered preventive when they are not performed as part of ongoing care for a diagnosed illness.

  9. When I pay the full cost of non-preventive prescriptions before the deductible is met, do these costs apply to meeting the deductible and the out-of-pocket maximum?

    Yes.  Medical, prescription and behavioral health costs for covered services paid out-of-pocket apply to the deductible.  Likewise, all costs for covered services apply to the out-of-pocket maximum. 

  10. What costs don’t apply to the deductible or out-of-pocket maximum?

    Costs for services or charges not covered or excluded under the Anthem PPO HDHP plan do not apply. These include amounts above the Maximum Allowable Amounts when Out-of-Network providers are used.

  11. Can I use my TSB, FSA, or HRA funds before the deductible is met?

    Maybe. If you are not contributing to a Health Savings Account (HSA), then yes, you can use your TSB, FSA or HRA accounts for any healthcare related expenses approved by the IRS.

    However, if you are making contributions to an HSA, you are not able to use TSB, FSA or HRA funds to cover the HDHP deductible expenses. During the plan deductible phase, you can use funds in the Health Savings Account component of the plan. Funds in TSB, FSA and HRA accounts can only be used to pay for "limited" expenses: dental and vision and "post-deductible" medical and prescription expenses (expenses after the plan HDHP deductible is met).

C. Network Services and Providers
  1. Which physicians and hospitals can I use?

    The plan uses Anthem Blue Access in Indiana and Blue Cross & Blue Shield (“Blue Card” providers) in other states and overseas. (This is the same medical provider network that the Anthem PPO $500 Deductible plan uses.) You can still receive benefits if you use out-of-network providers, but you will have higher out-of-pocket costs.  See www.anthem.com or www.bluecares.com

  2. Which pharmacies can I use?

    Outpatient prescription drug benefits are through CVS Caremark. These are the same pharmacies that all the IU plans use; therefore, if you switch from another IU-sponsored medical plan to the Anthem PPO HDHP Plan, you don’t have to change pharmacies. You can still receive benefits if you use out-of-network providers, but you will have higher out-of-pocket costs.  Most pharmacies are in-network; for example, CVS, Wal-Mart, Target, Kroger, K-Mart, Marsh, and Meijer.

  3. Which behavioral health providers can I use?

    You can use Anthem Behavioral Health providers, the same network the PPO plans use.  Go to www.anthem.com for a list of in-network providers.

  4. If I enroll in this plan do I still get the benefit of Anthem’s preferential pricing when I pay out-of-pocket for network doctors, hospitals, therapists, and pharmacies?

    Yes. Anthem has negotiated discounts with network providers and pharmacies. You receive the highest level of benefits when you use them.

D. Preventive Services and Prescriptions
  1. How are preventive services covered?

Preventive care services are covered at 100% (1) when network providers are used and (2) when services are consistent with the U.S. Preventive Services Task Force guidelines and nationally recognized schedules. View a list of preventive medical services (PDF) here.

You may call Anthem customer service using the number on your ID card for additional information about these services or view the federal government’s websites:

  1. How are preventive prescriptions covered?

Affordable Care Act mandated preventive prescriptions are covered at 100%, no deductible, no coinsurance.  These include: contraceptives requiring a prescription—generic and brands without a generic equivalent; pediatric sodium fluoride, low dose aspirin, folic acid, Vitamin D2 and D3 for members age 65 and above; iron;  Tamoxifen; Raloxifene; and Tobacco cessation products and nicotine replacement (up to 180 day supply annually). Only the preventive strength, dosage, and form of these medicines are covered.

All other preventive prescriptions listed on the Preventive Drug List (PDF) are covered at 80%—no deductible applies.

E. Turning Age 65 (Medicare Eligible)
  1. I keep getting all these notices telling me to enroll in Medicare.  Do I have to enroll in Medicare when I turn 65?

    It depends. If you are going to begin drawing your social security income benefits, then you will be automatically enrolled in Medicare Part A and will not have the option to waive out of coverage.

    If you are not drawing your social security income yet, and you are currently covered by a group health plan (like IU’s medical plans), then you can postpone enrollment in Medicare parts A, B & D until you are no longer employed (i.e. retired).  Remaining on a group medical plan allows you to be eligible for a “Special Enrollment Period” once you leave. There is no late enrollment penalty if you sign up for Medicare during a Special Enrollment Period.

    Postponing enrollment in Medicare allows you to extend the time you have to contribute to your HSA. However, be aware that if you choose to delay your Medicare enrollment until after your initial eligibility period (age 65), when you do eventually enroll in Medicare, Medicare will set the effective date of your Medicare Part A coverage either back 6 months or to your 65th birthday, whichever is most recent. That may mean your eligibility to make contributions to your HSA will be prorated for the year.

    For more information go to the Medicare website and read their “Medicare and You” handbook.

  2. What happens if I enroll in Medicare Part A?

    With regards to your medical plan, nothing changes.  The Anthem PPO HDHP would be your primary insurance coverage and all medical claims would go through the IU plan first.  There is no real benefit to being on both Medicare Part A and an IU medical plan.

    However, as of the effective date of your enrollment in Medicare, you are no longer eligible to make tax-free contributions to your HSA.

    If you enroll mid-year in Medicare, your contribution maximum for that year will be pro-rated based on the number of months that you were an eligible individual.
    For example:

    • You enroll in Medicare effective May 1, 2018.
    • You will have been an eligible individual for only 4 months (January, February, March and April). 
    • You would only be eligible to contribute 4/12ths of the IRS annual maximum to your account (don’t forget to include the catch-up contribution).
      • Employee only coverage =  $4,450 annual maximum x 4/12ths = $1,483
      • Family coverage = $7,900 annual maximum x 4/12ths =  $2,633
    • Any amounts contributed to your HSA account (IU’s contributions plus your own contributions) in excess of those figures would be considered to be “excess contributions” by the IRS and would not be eligible to remain tax-free in your HSA account.
  3. Contact Nyhart for instructions on how to remove “excess contributions” from your HSA at 800-284-8412 or at .

    Review IRS Publication 969 (PDF) and Instructions for IRS Form 8889 (PDF) for further details.

  4. Can I still use my HSA funds tax-free after I turn 65?  After I sign up for Medicare?
  5. Yes!  For however long you maintain a balance in your HSA account you can continue to use that balance tax-free for IRS qualified health expenses.

    Additionally, since you are now age 65, the IRS allows you to use the funds in your HSA for other expenses as well.  Any funds that you use for non-qualified health expenses (i.e. rent, groceries, vacation, etc.) you would need to report at year end as “taxable income” and pay taxes on the amount spent; however, you would not have to pay any penalty for using those funds for non-health related expenses.

  6. What happens if I don’t withdraw my excess contributions prior to April 15th of the following year?

    You must pay a 6% excise tax on any excess contribution and on any earnings on the excess contribution dollars. If in the next year you decreased your maximum contribution by the amount of your excess contribution made the year before, you do not have to pay the 6% excise tax again. However, for as long as you leave the excess contribution in, you will need to pay an annual 6% excise tax on this amount and its earnings.

    Please contact your tax advisor if you have additional questions.

    Contact Nyhart for instructions on how to remove “excess contributions” from your HSA at 800-284-8412 or at .

    Review IRS Publication 969 (PDF) and Instructions for IRS Form 8889 (PDF) for further details.

  7. I am collecting my spouse’s social security benefits and covered under an HDHP, can I still make tax-free contributions to my HSA?
  8. No. If you are drawing your or your spouse’s social security benefits, your enrollment in Medicare Part A will be automatic and you will no longer be eligible to make contributions to an HSA as of the effective date of your Medicare enrollment. Complete the HSA Enrollment/Change form (PDF) to suspend or stop your HSA Contributions during 2018. Then determine if you have excess contributions for that year. Details on the calculation of the IRS prorated maximum can be found in IRS publication 969 (PDF). If your contributions have exceeded the IRS maximum, you must work with Nyhart to resolve the excess contribution issue.

    If you choose to continue to participate in the HSA plan when you are ineligible to make tax-free contributions, you will need to complete a distribution request form each year to remove all ineligible contributions (IU’s contribution and your contributions) and any earnings on those contributions and then claim those dollars on your annual income tax return as taxable income.

    Contact Nyhart for instructions on how to remove “excess contributions” from your HSA at 800-284-8412 or at .

    Review IRS Publication 969 (PDF) and Instructions for IRS Form 8889 (PDF) for further details.

F. Vision Wear Benefit
  1. Does my health care coverage include vision?

Yes. The Vision Wear benefit is provided through Anthem Blue View Vision and is included if you enrolled in the Anthem PPO HDHP plan. Covered vision services have their own schedule of benefits and network providers separate from your medical benefits. Additionally, the medical plan deductibles and coinsurance do not apply to vision benefits, and the amount you pay for vision services does not accumulate toward the medical plan deductible or out-of-pocket maximums.

  1. What does my vision coverage include?

The vision benefit is for routine eye care and corrective eye care only. For medical treatment of the eyes, visit a medical network eye care physician. Medical eye care includes services for such conditions as eye injuries, glaucoma, and retinal detachment. The medical deductible, coinsurance and out-of-pocket maximums apply to medical eye services.

Benefits include:

  • A routine eye exam every 12 months, with a $10 copay.
  • Frames, lenses and contacts covered with specific allowances and copays for in-network providers. See the Vision Wear Benefit page for more information.

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