Preferred In-Network – Bowdoin College works with a group of health care providers known as “Preferred In-Network” providers with additional cost savings.
In-Network – Anthem has contracts with many providers in Maine and across the United States, known as “In-Network” providers. Anthem has special rates with these providers, so if you go to an In-Network doctor or hospital you will be able to pay less out of pocket. You can see who is on the list of network providers at Anthem’s website.
Out-of-Network – With a PPO plan, you do not have to go to an In-Network or Preferred-In-Network provider if you do not wish to. However, because Out-of-Network providers do not have a contract with Anthem, it will cost more for both you and the College. It is important to understand that if you receive services from an Out-of-Network doctor or hospital, the health plan will pay benefits based on the “maximum allowances.” This means that any amount that an Out-of-Network doctor or hospital charges that is above the maximum allowance will be billed to you directly before the Out-of-Network benefits begin to pay. This can mean significantly higher out-of-pocket costs to you. For example, if an Out-of-Network doctor charges $175 for an office visit and the maximum allowance is $100, you will have to pay $75 before the deductible and coinsurance are applied.
Deductible– The deductible is the amount of money you need to pay before the insurance pays. The Preferred In-Network deductible on the health plan is $500 for an individual or $1,000 for a family and the In-Network deductible is $750 for an individual and $1,500 for a family. For many of the services covered by the health plan, you will need to meet your deductible before the benefit applies.
Copayment (Copay) – For some services and for prescription drugs, you will have to pay a copay. A copay is the amount of money you pay for a service, separate from your deductible. Your copay is usually a small percentage of the overall cost, especially if you use In-Network providers. For example, if you go to an In-Network primary care doctor for an office visit, you pay $20 and the insurance company pays the rest. Copays are a set dollar amount.
Coinsurance – Coinsurance is the percent of the cost of your care that you need to pay after you have paid your deductible. For Preferred In-Network services, the co-insurance is 10%, for the In-Network services it is 30% and for Out-of-Network services it is 50%.
Out-of-Pocket Maximum – The “Out-of-Pocket” maximum is the total amount of money (deductible plus coinsurance plus medical co-payments) that you will pay for medical services in a benefit year (calendar year). Benefits are paid at 100% for the remainder of the calendar year once you have reached your out-of-pocket maximum. There is a separate out-of-pocket maximum for prescription drug copayments: $3,350/individual and $6,700/family. Out-of-Network charges that are in excess of the maximum allowance do not count toward your out-of-pocket maximum. The preferred in-network out of-pocket calendar year limit is $3,000 per individual/$6,000 per family. The in-network out-of-pocket calendar year limit is $4,000 per individual/$8,000 per family.