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HDHP

The High-Deductible Health Plan (HDHP)—like the CoreSource PPO and HumanaPPO coverage options—offers two levels of coverage. Under this coverage option, you decide at any time whether to use PPO participating providers or non-participating providers. When you use:

Participating providers—you receive maximum benefits and reduce your out-of-pocket costs.
Non-participating providers—your benefits are lower, your out-of-pocket costs are higher and there are claim forms to file.

The HDHP offers you access to the CoreSource PPO network of participating providers. Under this coverage option, there are deductibles and coinsurance amounts to pay.

If you use participating providers, the HDHP covers eligible expenses at 80%. When you use non-participating providers for your medically necessary care, the plan covers most expenses at 60% of reasonable and customary charges according to the plan’s reimbursement schedule.

Another important feature of HDHP coverage is that it pays benefits for preventive care services according to a schedule of benefits without having to meet your deductible first. In other words, benefits for preventive care services are not subject to a deductible. This makes it easier to maintain your family’s health by taking advantage of preventive care services such as immunizations, check ups and screenings.

Not sure if participating in the HDHP is right for you? Here are a few questions you might want to ask yourself:

Do you prefer to pay a set amount when you see the doctor? In the HDHP, you will pay the full cost of your doctor appointments until you meet the deductible; once you do, you will pay a coinsurance fee, which is a percentage of the total cost of the service. If you elect HMO coverage, you pay a set copayment for most covered services.
Do you mind paying a deductible before benefits are paid? With HDHP coverage, your deductible is higher than under either of the two PPO coverage options that Advocate offers. In the HMO, there is no deductible to meet before benefits begin (though a copayment does apply to most covered services).
Do you want to take advantage of the potential tax savings available through your participation in a Health Savings Account? You may participate in a Health Savings Account only if you elect HDHP coverage.
Do you need flexibility in terms of which physicians you can see? In this coverage option—as in the PPOs—you can see any doctor you choose, but benefits are payable at different levels depending on whether the doctor is a member of the network of participating providers. In the HMO, you must select a primary care physician (PCP), who then coordinates all of your care, including care provided by a specialist. Benefits are only payable if you see your PCP or other HMO physicians to which your PCP provides a referral.

This is a brief description of the HDHP coverage option, which is administered by CoreSource. This is not the plan document and doesn’t include all of the benefits, limitations and exclusions of the plan. Other sources of plan information are the highlights brochure, Advocate Health Care Medical Plan Summary (color version) (B&W "print-friendly" version) , certificate of coverage, certificate of insurance, or Plan Summary. 

For answers to questions about general plan features or claims, contact the plan administrator, CoreSource — by phone at 1-888-212-7385 (7 a.m. to 5 p.m., Monday-Friday), or online at www.coresource.com. See the Benefits Directory for the phone number to call for Behavioral Health precertification, and for an address for written correspondence.

How the HDHP works
The High-Deductible Health Plan offers PPO-style coverage comparable to the current CoreSource PPO with the following annual deductibles, annual out-of-pocket expense limits and maximum lifetime benefits:

  Participating providers  Nonparticipating providers 
Annual deductibles $2,000 individual
$4,000 family		 $3,000 individual
$6,000 family
Maximum annual out-of-pocket expense limits $2,000 individual
$4,000 family		 $5,000 individual
$10,000 family
Maximum lifetime benefit for infertility (not including pharmacy) $25,000 $25,000
Maximum lifetime benefit $1,000,000 $1,000,000

Important! Under HDHP coverage, the family deductible is an aggregate deductible. This means that if you elect associate + 1 or family coverage under this plan, you will need to satisfy the entire family deductible amount—$4,000 or $6,000—before any benefits (other than for preventive care) will be paid under this plan.

The following features also apply to your HDHP coverage:

Non-duplication of benefits does not apply.
You must first pay the annual deductible amounts before coverage begins for all services except preventive care services (to which the deductible does not apply).
Preventive care services include those listed under Preventive benefits in PPO/HDHP covered services
Your prescription drug benefits are included in your overall medical expense and will be subject to this coverage option’s annual deductibles.
If you elect associate + 1 or family coverage, you must meet the family deductible before benefits—other than for preventive services—begin. This is known as an aggregate deductible.
A new deductible must be satisfied each calendar year.
Hospital emergency room copayments cannot be used toward your annual deductibles or maximum out-of-pocket expense amounts.
Annual deductibles and charges in excess of reasonable and customary charges will not apply toward your maximum out-of-pocket expense limits.
Your portion of reasonable and customary charges will be applied equally toward satisfying participating and non-participating deductibles and maximum out-of-pocket expense amounts.

Example:

Participating annual deductible = $2,000

Non-participating annual deductible = $3,000

The first $2,000 you pay for services, regardless of where you receive services, will go toward satisfying both your participating and non-participating deductibles. If you incur future participating expenses, your annual deductible is met. Meanwhile, you only have to pay an additional $1,000 for services to meet your non-participating annual deductible if you choose a non-participating provider. This same principle applies to your maximum out-of-pocket amount. Whether you see a participating or non-participating provider, benefits for preventive services are not subject to a deductible.
When you have the opportunity to use an Advocate facility, Advocate will waive the amount you would otherwise pay—20% coinsurance under HDHP coverage. This waiver will NOT apply to emergency room copayments, nor will it apply to the charges of non-Advocate facilities—even if Advocate does not provide the service you need or if an Advocate facility is busy (“on by-pass”) at the time the service is provide.
If you use non-participating providers, you will be responsible for any amount over the reasonable and customary charges in addition to the deductibles and coinsurance.
Not all services are listed. Eligible medical services not available at participating providers will be paid at 80% of reasonable and customary charges, subject to the annual deductible and maximum out-of-pocket limit, provided you receive prior plan approval.

Reminder: If you choose HDHP coverage, you also may choose to establish a personal Health Savings Account (HSA) to which you can make tax-deductible contributions each year and use this money to reimburse yourself the cost of eligible medical expenses—including any amount you pay in deductibles throughout the year—on a tax-free basis. Note: If you open an HSA, you also can participate in a Health Care Flexible Spending Account (FSA). You will be able to use your HSA to reimburse yourself for any out-of-pocket expenses for services that are covered under the HDHP and your Health Care FSA to reimburse yourself for any out-of-pocket expenses that are not covered expenses under the HDHP (such as vision care, orthodontia and certain over-the-counter medications).