Employee Medical Plan Options

The CHP EPO is an Exclusive Provider Organization (EPO). The EPO is a network of Hospitals, Physicians, medical laboratories, and other Health Care Providers who are located within a Service Area and who have agreed to provide Medically Necessary services and supplies for favorable negotiated discount fees applicable only to EPO Plan participants.

• All care in the County Health Plan EPO must be obtained within the plan network, except if you have an authorized referral from a network provider or if you have an emergency.

The EPO Plan offers you affordable out-of-pocket costs, with access to the doctors and hospitals you trust. You are free to visit any doctor or hospital in the EPO network where you pay an affordable copay or deductible, without the hassle of filling out claim forms. Covered services must be provided by EPO network providers. Most doctor and specialist office visits are available at a $50 copay and most in-network preventive services, such as well baby/child visits, routine physicals, mammograms, and routine preventive screenings are covered at no cost. Other in-network services are covered at 80% after the deductible ($500 per individual or $1,500 per family) is met.

The CHP PPO is a Preferred Provider Organization (PPO).  A PPO is a medical plan that offers you a choice between an in-network group of providers who offer their services at discounted rates and out-of-network providers without discounted rates. Under a PPO plan, you may choose the level of benefits you receive based on the providers you use when you receive care. Most in-network doctor and specialist office visits are available at a $20 copay and most in-network preventive services such as well baby/child visits, immunizations, routine physicals, mammograms, and routine preventive screenings are covered at no cost. Other in-network services are covered at 90% after the deductible ($300 per individual or $900 per family) is met.

The Traditional HMO plans have a higher monthly premium with no deductible, low copays, and a lower out of pocket annual maximum, making your total annual expenses more predictable.  Hospitalization, radiology, lab tests and most preventive services are also covered at no cost. Generally, specialist services require a referral from your primary care physician (PCP) and you must use the provider’s network unless you have an out-of-area urgent or emergency situation or an approved referral.

The Hospital Services DHMO plans offer a lower monthly premium with deductibles only on hospital related services, including emergency room visits, inpatient stays, and outpatient surgery.  You pay the full cost of these services up to the deductible then a 20% coinsurance until you reach your out-of-pocket maximum. The out-of-pocket maximum includes the calendar year deductible, copays, and coinsurance. Physician and specialist visits, radiology, lab tests, and prescriptions have a flat copay, without having to meet the deductible. Preventative services are covered at no cost.

The Deductible First HDHP plans offer the lowest monthly premium and requires a member to meet the calendar year deductible FIRST before ANY plan benefits will be paid, except covered preventive services. Members will pay 100% of the doctor office visits, radiology services, lab tests, prescriptions, hospitalizations, etc., until the calendar year deductible is met. Once the deductible is met, covered medical, hospital, and prescription benefits will be provided for a copay or coinsurance amount. The calendar year out-of-pocket maximum includes calendar year deductibles, copays, and coinsurance.

Please Note: Dependents will not be able to contribute to an HSA through their employer if enrolled in a Deductible First HDHP plan. If you (the employee) elect to enroll in the Deductible First HDHP, which qualifies as a HSA qualified high deductible health plan, and you have a Flexible Spending Account (FSA) and/or a Health Reimbursement Arrangement (HRA), be advised that under IRS rules you are NOT allowed to contribute to a Health Savings Account (HSA). Because FSA and HRA accounts can be used to reimburse your out-of-pocket medical expenses, the IRS does not allow you to also contribute to a HSA at the same time, as it is considered prohibited health coverage. While the County does not offer an HSA, this rule applies to all enrolled dependents in this plan.