cost sharing plans - idaho health insurance lit/3-190-cost-sharing-plan... · cost sharing plans...

Form No. 3-190 (10-14) Policy Form Numbers: 18-062-01/15 18-063-01/15 18-090-01/15

18-091-01/15 18-092-01/15 18-095-01/15 18-096-01/15

18-097-01/15 18-107-01/15 18-108-01/15 18-109-01/15

18-116-01/15 18-117-01/15 18-118-01/15 18-207-01/15

18-208-01/15 18-209-01/15 18-212-01/15 18-213-01/15

18-214-01/15 18-217-01/15 18-218-01/15 18-219-01/15

18-227-01/15 18-228-01/15 18-229-01/15

Cost Sharing Plans

for Individuals from

Blue Cross of IdahoChoose coverage

that fits.

HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Individuals

ANNUAL HOUSEHOLD INCOME

Family Size

CSR 73 CSR 87 CSR 94

1 $23,340 - $29,175 $17,505 - $23,340 $11,670 - $17,505

2 $31,460 - $39,325 $23,595 - $31,460 $15,730 - $23,595

3 $39, 580 - $49,475 $29,685 - $39,580 $19,790 - $29,685

4 $47,700 - $59,625 $35,775 - $47,700 $23,850 - $35,775

5 $55,820 - $69,775 $41,865 - $55,820 $27,910 - $41,865

6 $63, 940 - $79,925 $47,955 - $63,940 $31,970 - $47,955

7 $72, 060 - $90,075 $54,045 - $72,060 $36,030 - $54,045

8 $80,180 - $100,225 $60,135 - $80,180 $40,090 - $60,135

*This chart is for reference only. Your Health Idaho will determine your actual CSR eligibility.

GET AN EVEN BIGGER BREAK ON COSTS!If you qualify for financial assistance with you rmonthly premium payment, you might also qualify for additional savings on the out-of-pocket costs you have to pay when you use your insurance. This type of savings is called a cost-sharing reduction, or CSR, and is a Silver plan with reduced costs for deductibles, coinsurance or copayments.

If you qualify for a CSR, our Silver plans automatically have reduced out-of-pocket costs. CSRs are different from the monthly premium assistance because they are not tax credits and do not have to be listed when you file your taxes.

To enroll in a CSR plan, you have to buy your health insurance through the Idaho Health Insurance Exchange, called Your Health Idaho. This website, yourhealthidaho.org, will ask

you for information about your family, income and job and show you the CSR level you qualify for. Then you can choose a plan and enroll online.

YOU CAN GET THIS REDUCTION IF

• You get health insurance through Your Health Idaho • Your annual household income is below a certain level • You choose one of the Silver health insurance plans

Don’t forget—if you qualify for a CSR level, you also qualify for financial assistance with your monthly insurance premiums. Members of Native American tribes qualify for a separate CSR. See our Tribal Health Insurance Plans brochure for details.

Note: The cost-sharing reductions only apply to healthcare you get from an in-network provider. If you choose a Silver Connect plan, it is important to review the list of doctors in the ConnectedCare network to see if the plan meets your needs. You can search the list of providers at bcidaho.com/findaprovider.

CHOOSE COVERAGE THAT FITS – bcidaho.com

BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS

Benefit details are for in-network coverage only. Not a comprehensive list of benefits. See our Health Insurance plans for Individuals brochure for a larger list of benefit and plan exclusions and limitations.

CSR 73 SILVER CHOICE & SILVER CONNECT 4000

SILVER CHOICE & SILVER CONNECT 3000


SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLE

Benefit Details

DeductibleBase

$4,000 individual

$8,000 family

You pay $2,900

individual $5,800 family

Base $3,000


You pay $2,500


Base $2,000


You pay $2,000


Base $0 You pay $0

Coinsurance Base 30% You pay 30% Base 30% You pay 30% Base 30% You pay 30% Base 50% You pay 50%

Annual Out-of-Pocket Maximum

Base $6,350

individual $12,700

family

You pay $5,200

individual $10,400

family

Base $6,350

individual $12,700

family

You pay $5,200

individual $10,400

family

Base $6,350

individual $12,700

family

You pay $4,650


Base $6,350

individual $12,700

family

You pay $5,200

individual $10,400

family

Brand-name Prescription

Deductible

Base $2,350 per person

You pay $2,300

per personBase $1,000

per personYou pay $1,000

per personBase $1,000

per personYou pay $1,000

per personBase $0

per personYou pay $0 per person




SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLE

Benefit Details

DeductibleBase

$4,000 individual

$8,000 family

You pay $150

individual $300 family

Base $3,000


You pay $150


Base $2,000


You pay $150


Base $0 You pay $0



Base $6,350

individual $12,700

family

You pay $2,250


Base $6,350

individual $12,700

family

You pay $2,250


Base $6,350

individual $12,700

family

You pay $2,250


Base $6,350

individual $12,700

family

You pay $2,250



Deductible


You pay $150 per person





Base $0 per person





SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLEBenefit Details

DeductibleBase

$4,000 individual

$8,000 familyYou pay $0

Base $3,000


You pay $0Base

$2,000 individual

$4,000 familyYou pay $0 Base $0 You pay $0



Base $6,350

individual $12,700

family

You pay $1,000


Base $6,350

individual $12,700

family

You pay $900


Base $6,350

individual $12,700

family

You pay $700


Base $6,350

individual $12,700

family

You pay $1,750



Deductible







Base $0 per person


STREET ADDRESS

1010 17th Street Lewiston, ID 83501

MAILING ADDRESS

P.O. Box 1468 Lewiston, ID 83501 208-746-0531

Lewiston

STREET ADDRESS

275 South 5th Avenue Suite 150

Pocatello, ID 83201

MAILING ADDRESS

P.O. Box 2578 Pocatello, ID 83206 208-232-6206

Pocatello

STREET ADDRESS

1431 North Fillmore Street Suite 200

Twin Falls, ID 83301

MAILING ADDRESS

P.O. Box 5025 Twin Falls, ID 83303-5025 208-733-7258

Twin Falls

STREET ADDRESS

3000 East Pine Avenue Meridian, ID 83642-5995

MAILING ADDRESS

P.O. Box 7408 Boise, ID 83707 208-387-6683 800-365-2345

Meridian

CLAIMS INQUIRIES

(208) 331-7347 | 800-627-1188

STREET ADDRESS

1910 Channing WayIdaho Falls, ID 83404

MAILING ADDRESS

P.O. Box 2287 Idaho Falls, ID 83403 208-522-8813

Idaho Falls

Coeur d’Alene1450 Northwest Boulevard, Suite 106

Coeur d’Alene, ID 83814 208-666-1495

P.O. Box 7408 · Boise, ID · 83707 1 888 GO CROSS (1 888-462-7677)

bcidaho.com

© 2014 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association

cost sharing plans - idaho health insurance lit/3-190-cost-sharing-plan... · cost sharing plans...

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