Is Anthem an HDHP PPO? Understanding Anthem’s High Deductible Health Plan

When reviewing health insurance options, you may come across plan names and acronyms that can be confusing. Anthem offers a type of plan called an HDHP PPO. What exactly does this mean?

Below we’ll explain what an HDHP and PPO are, Anthem’s HDHP PPO plan details, how the coverage works, and who this type of plan is best suited for.

What is an HDHP?

HDHP stands for “high deductible health plan.” As the name suggests, these plans have a higher deductible amount compared to traditional health insurance.

The deductible is the annual amount you must pay out-of-pocket for healthcare expenses before your insurance kicks in to cover part of the costs. Generally, the deductible on HDHPs ranges from $1,400 to $7,000 for individual coverage, or $2,800 to $14,000 for a family.

With an HDHP, you pay 100% of medical and prescription costs yourself until meeting the deductible. Preventive services like annual physicals are fully covered by the plan and not subject to the deductible.

The benefit of a high deductible plan is the lower monthly premiums. However, you take on more upfront medical costs before coverage applies. HDHPs are a good fit for healthy individuals who don’t expect frequent medical needs.

What Does PPO Mean?

PPO stands for “Preferred Provider Organization.” This refers to the network of doctors, hospitals, and other healthcare providers contracted by the insurance company.

PPOs offer two levels of coverage:

• In-network: Higher level of coverage and discounted rates when you use healthcare providers within the PPO network. You pay a lower coinsurance percentage after meeting the deductible.

• Out-of-network: You can still see providers outside the PPO network, but your out-of-pocket costs will be higher. The plan pays a lower percentage after deductible, so your share of bills is greater.

The flexibility to see any provider is an advantage of PPO plans. However, you receive the best benefit by choosing in-network providers. Related terms you may see are HMO (Health Maintenance Organization) and EPO (Exclusive Provider Organization) plans. HMOs require you to have a primary care physician and get referrals to see specialists. EPOs only cover in-network providers.

Overview of Anthem’s HDHP PPO Plan

Now that we’ve defined the key terms, here’s an overview of how Anthem’s HDHP PPO works:

• This plan combines a high deductible health plan with a broad PPO provider network.

• The monthly premiums are lower than traditional plans since you take on more upfront costs.

• The annual deductible is at least $1,400 for individual or $2,800 for a family.

• You pay 100% of medical and prescription costs out-of-pocket until the deductible is reached. The exception is preventive care which is covered at 100% by the plan from day one.

• After reaching the deductible, you pay a percentage coinsurance (e.g. 20%) until you reach the annual out-of-pocket maximum. Then the plan covers 100% of covered services.

• Out-of-network costs count separately toward a higher out-of-pocket maximum limit.

• The plan covers medical, behavioral health, prescription drugs, and vision services.

Using in-network PPO providers is ideal, but not required. You can see any doctor or hospital, but out-of-network costs will be higher.

Anthem HDHP PPO Plan Details

Below are details of what the Anthem HDHP PPO plan covers and typical costs. This can vary slightly by state and employer, so be sure to check your specific plan’s benefit summary:

Monthly Premiums

• HDHP premiums are typically 15-30% lower compared to traditional plans.
• Premium amount depends on who you cover – employee only, employee + spouse, employee + child(ren), or family coverage.
• Factors like your age and location may also impact your premium.

Annual Deductible

• Often a minimum of $1,400 for individual or $2,800 for family coverage.
• Must be paid before coinsurance kicks in.
• Separate deductible amounts apply for in-network vs. out-of-network services.
• Deductible resets January 1st each year.

Coinsurance

• Once deductible is met, you pay a percentage of costs.
• Typically 20% in-network and 40% out-of-network until you reach the out-of-pocket max.
• In-network and out-of-network coinsurance is calculated separately.

Out-of-Pocket Maximum

• Total you pay annually including deductible and coinsurance.
• May range from $2,000-$7,000 for individual or $4,000-$14,000 for family.
• Separate in-network and out-of-network out-of-pocket maximums.

Preventive Services

• Covered at 100% – not subject to deductible.
• Includes routine physicals, cancer screenings, immunizations, women’s exams, and lab tests.

Hospital Services

• Subject to deductible, then 20% coinsurance in-network.
• Separate coinsurance of 40% or more out-of-network after deductible.

Outpatient Services

• Doctor visits, urgent care, diagnostic tests have deductible then 20% coinsurance in-network.
• Therapy services, home healthcare also fall under this category.

Prescription Drugs

• Must meet deductible first, then typical coinsurance is 20% in-network retail/mail-order.
• Out-of-network likely not covered.

Vision Services

• Eye exams may be covered 100% in-network without deductible.
• Hardware is often covered with copays or allowances after you meet deductible.

Who is an HDHP PPO Good For?

An HDHP with the flexibility of a PPO network works well for certain individuals:

• Younger, healthy people – With less frequent medical needs, you can save money on premiums and take advantage of tax-free contributions to the linked Health Savings Account (HSA).

• Middle to higher income earners – You can comfortably afford to pay the higher deductible if significant medical expenses arise unexpectedly.

• Families with kids – Preventive pediatric services like well child visits are covered at no cost. An HSA allows tax-free savings for future healthcare costs.

• Price-conscious consumers – You’re motivated to find the best value for medical services due to higher cost-sharing.

• Anyone wanting network flexibility – The freedom to see out-of-network providers when needed or while traveling is helpful.

• Small business owners/entrepreneurs – The premium savings and tax perks of HSAs can benefit individual buyers and small groups.

Be sure to evaluate whether the lower premiums outweigh taking on more potential risk upfront with the deductible and coinsurance. Also consider eligibility factors for opening an HSA if that is your goal.

How Anthem HDHPs Work with Health Savings Accounts

A major perk of an HDHP is the ability to pair it with a Health Savings Account (HSA). An HSA provides triple tax advantages:

• Tax-deductible contributions
• Tax-free growth on invested funds
• Tax-free withdrawals for qualified medical expenses

Money in your HSA can be used to cover the high deductible, coinsurance, prescriptions, dental care, vision expenses, and more. If you maintain a balance in your HSA, it can grow and rollover year to year.

Key facts about how HSAs work with HDHPs:

• You must have an eligible HDHP plan to open an HSA.

• Annual HSA contributions usually max out at $3,850 for individuals or $7,750 for families.

• You can use HSA funds for qualified expenses right away or save them for the future.

• HSA balances roll over annually if you stay enrolled in an eligible HDHP.

• Once you turn 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income tax).

Consult a tax professional to understand all the HSA eligibility rules. But the combination of an HDHP PPO with an HSA can be financially beneficial for many consumers.

The Bottom Line

While it has advantages, this type of plan also shifts more risk to the insured to cover medical costs upfront before insurance protections kick in. Understanding how an HDHP PPO works allows