About the Plans
What does PPO stand for?
PPO stands for Preferred Provider Organization. PPO is a type of health plan with a network of providers who are "preferred," that is, a member can visit these preferred in-network physicians and does not need to choose a Primary Care Physician (PCP).
What is the difference between the PPO+ and HDHP networks?
The PPO+ Plan and HDHP use the same network called a Preferred Provider Organization (PPO).
Do I need a referral on either of the MIT health plans offered?
No. Provider referrals are not required for either plan.
Do I still need an authorization (also known as prior authorization) for some services on the health plans?
An authorization is an approval of services/benefits before they are obtained. You will still need prior authorizations for some services.
Can I keep my Primary Care Provider (PCP) at MIT Health or my PCP in the BCBS HMO Blue New England network?
Yes, if you wish. but you are not required to designate a PCP.
Can I have a PCP at MIT Health while members of my family have a PCP elsewhere?
Yes, but you are not required to designate a PCP.
What is a deductible?
A deductible is the amount you pay for covered medical plan services before the insurance plan starts to pay.
How does the deductible work with the BCBS PPO+ Plan?
The BCBS PPO+ Plan has the following deductibles: $150/individual and $300/individual + spouse/domestic partner, individual + child(ren), and family. This deductible applies to higher cost services such as inpatient hospital, outpatient surgery, emergency room, and imaging.
The $300 deductible is embedded. This means it can be met by eligible costs incurred by any combination of members enrolled under the same plan, but no one member will have to pay more than the $150 per member deductible. The plan begins to make payments once as soon as one member has reached their individual deductible.
How does the deductible work with the BCBS HDHP?
The HDHP has the following deductibles: $1,600/individual and $3,200/individual + spouse/domestic partner, individual + child(ren), and family.
The $3,200 deductible is aggregate. This means it can be met by eligible costs incurred by any combination of members enrolled under the same plan, but an individual member may pay more than the per member deductible. The entire family deductible must be met before the plan pays for services for any one member of the family.
What is a copayment (copay)?
A copayment (copay) is a set dollar amount you pay for each visit, after any applicable deductible is met.
What is co-insurance?
The portion of eligible expenses that plan members are responsible for paying, most often after the deductible is met. Co-insurance is usually determined as a percentage of the total provider's actual charge, or the allowed amount.
What does "allowed amount" mean?
This is the maximum payment the plan will pay for covered healthcare services. It sometimes may also be called "eligible expense" or "negotiated rate."
What is an Out-Of-Pocket (OOP) maximum and how much are they?
The OOP maximum is the most a member will pay per year for covered services. Both of MIT's health plans have an embedded OOP maximum. This means it can be met by eligible costs incurred by any combination of members enrolled under the same plan, but no one member of the family will have to pay more than the per member OOP.
The OOP maximums for the PPO+ Plan are $2,500 per member and $5,000 per family. The OOP maximums for the HDHP are $3,000 per member and $6,000 per family.
What is a specialist?
Specialists are providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose, and throat), or specific procedures (e.g., oral surgery).
What does out-of-network coverage mean?
An out-of-network deductible allows employees to seek services outside of the BCBS network, however, deductible and co-insurance apply. The term refers to physicians, hospitals or other healthcare providers who do not participate in an insurer's (BCBS) provider network. This means that the out-of-network provider has not signed a contract agreeing to accept the insurer’s negotiated prices. For example, many mental health providers do not belong to a provider network.
Other
Is there an age limit on gender-affirming care services?
Yes. Surgical services are typically covered for members age 18 and older, but BCBS will review authorizations on a case-by-case basis if the member is under age 18.
How is the voluntary egg cryopreservation different from medically-necessary egg cryopreservation?
The benefits are similar. Any member who meets the age requirement (under age 44) is eligible for the voluntary egg cryopreservation, and any member who is diagnosed with a medical condition that is expected to render them infertile is eligible for the medically-necessary egg cryopreservation benefit. In both cases, the plan covers the egg retrieval, freezing, and storage.
For voluntary egg cryopreservation, members have a $15,000 lifetime maximum for this benefit with no egg storage time limit (storage is covered until you hit the $15,000 maximum). Members who use medically-necessary cryopreservation have no lifetime maximum with a 24-month time limit for egg storage.