Major Medical

Personal Choice 90 / 10 Coinsurance Plan

Independence Blue Cross Personal Choice 90/10 Coinsurance Plan. Coinsurance is the percentage of the cost of care you are required to pay after your health plan pays. A 90/10 Coinsurance means that the total cost of an In-Network hospital visit is shared between the Fund and the Participant at a percentage of the bill. The Fund will pay 90% of the total Blue Cross allowance and the remaining 10% is the Participants responsibility until their out-of-pocket maximum is met ($2,000 individual, $4,000 family). Once an individual or family has reached their OOP Max, the Plan will pay 100% for all further In-Network claims for the duration of the Plan Year.

Maximize your coverage by accessing care through Personal Choice’s extensive network of  hospitals, doctors and specialists. You do not need to enroll with a primary care physician and you never need a referral.

(800) ASK-BLUE

For a more in-depth explanation of your benefits, please refer to the full Health & Welfare Summary Plan Description.

Major Medical FAQs

What is the difference between a deductible, a co-pay, and coinsurance?

A deductible is the initial amount of money you must pay for health care services before your insurance starts to pay for covered services. For all In Network Claims through Blue Cross or Mental Health Consultants, your coverage does not have a deductible.

A co-pay is a fixed dollar amount you are required to pay for health care services. For example, if you visit a Participating Chiropractor, the copay is $5.

Coinsurance is the set percentage of the allowed amount you are required to pay for health care services. Currently, the coinsurance amount of an office visit through a Participating Blue Cross provider is 10%.

 

Is there an “Out-of-Pocket Maximum,” and what does that mean?

Out-of-Pocket Max means the total amount of money you can spend of your pocket in a Plan Year (May 1st through April 30th). The out-of-pocket maximum for In-Network Services through IBX and MHC is $2,000.00 for an individual and $4,000.00 for a family.

 

Please note, there is a separate out-of-pocket maximum for Out of Network Services through IBX and MHC is $15,000.00 for an individual and $30,000.00 for a family after the Out of Network Deductible is met.

 

What is the Out-of-Network Out-of-Pocket?

If you utilize Out-of-Network Facilities, after the deductible ($10,000.00 individual/$20,000.00 family) is met, your Out of Pocket Maximum is a combination of your copays and coinsurances with a limit of $15,000.00 for individuals and $30,000.00 for family.

Can I use an Urgent Care Facility, or a Minute Clinic at a pharmacy?

Yes, you may utilize an Urgent Care Facility or a Minute Clinic at a pharmacy as long as they are participating with IBX. Urgent Care visits and all testing and procedures are covered at 10% a coinsurance amount of IBX’s allowed amount. Please visit www.ibx.com for a list of Participating Providers.

Is there a Deductible?

For In-Network claims processed through Independence Blue Cross Personal Choice (IBX) and Mental Health Consultants (MHC) there is currently NO DEDUCTIBLE.

 

For Out of Network claims processed through Independence Blue Cross Personal Choice (IBX) and Mental Health Consultants (MHC) there is a $10,000.00 deductible for an individual and a $20,000.00 deductible for a family. If you are seeking services and the provider is Out of Network, call IBX or MHC and ask for alternative physicians.

 

Where can I find a list of Participating Blue Cross Providers?

You may find a list of Participating Providers for Health Care Professionals on the Independence Blue Cross Website at www.ibx.com.  You may also contact Blue Cross directly at 1-800-275-2583.

What is considered Preventative Care?

Preventative Care encompasses procedures such as: Vaccinations, Immunizations, and Wellness Visits. Preventative Care eligibility will be determined by your Primary Care Physician based on medical necessity and your unique individual situation. All preventative care is covered at 100%. For a list of covered services click the following link for the Preventative Services Flyer.

Where do I send my Blue Cross Claims to?

If you visit a Blue Cross Participating Provider, there shouldn’t be any claims forms for you to submit. As long as you are supplying you Blue Cross Personal Choice Card beginning with the letters CBE, the provider will submit the claim for you.

If you have received an Explanation or Benefits or bill, stating that the claim was sent to Highmark Blue Shield please call Blue Cross at 1-800-275-2583 to have the claim directed to Blue Cross.

Are Doctor’s visits covered?

All Primary Care and Specialists’ visits at a Participating Blue Cross Provider are covered at 10% of IBX’s allowed amount. All testing and procedures done during your visit will be covered at 90% of IBX’s allowed amount. Please visit www.ibx.com for a list of Participating Providers.