The group medical, vision & life plans offer savings and comprehensive coverage for both large and small CPA firms across California. The plans offer the market leading Blue Cross Prudent Buyer provider network for the PPO and Blue Cross California Care for the HMO.

 

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ProtectPlus is a self-funded medical plan offered through the Group Insurance Trust of the California Society of CPAs. Because they operate their own plan, they design the benefits, rates and options. To provide outstanding service and value to the members, they have contracted with Blue Cross of California to use its comprehensive provider network and to process our claims. In effect, we've chosen what we believe are the best doctors and hospitals and the best administrators to provide the best benefits for you.

 

You and your employees will have the freedom to choose virtually any health care provider and no physician referral is required. It's up to you whether you go in-network and receive a higher benefit or go out-of-network and pay more. However, when you choose participating network providers, you will take advantage of negotiated rates, which lowers out-of-pocket expenses.

 

This chart summarizes the in-network primary benefits effective January 1, 2008, offered under each California CPA ProtectPlus Copay Plan option. It shows the insured's copayments and deductibles, then coinsurance paid by the member. ProtectPlus also provides out-of-network benefits. However, if you use out-of-network providers you should expect to pay a significantly greater portion of the eligible charges. Please Note: Your firm may offer any combination of the six copay plans, two HSA plans and one of the HMO plans.

 

In-Network Benefits
Protect 10 Protect 15 Protect 25 Protect 25 Enhanced Protect 35 Protect 45
Annual Deductible (combined in/out-of-network) $250 per member in/out-of-network
$500 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met
$250 per member in/out-of-network
$500 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met
$500 per member in/out-of-network
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met
$500 per member
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met unless otherwise stated
$500 per member in/out-of-network
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met
$0
Out-of-Pocket Maximum (annual) $2,500 per member
$5,000 family aggregate
$3,000 per member
$6,000 family aggregate
$4,000 per member
$8,000 family aggregate
$4,000 per member
$8,000 family aggregate
$5,000 per member
$10,000 family aggregate
$8,000 per member
$16,000 family aggregate
Plus hospital admission deductible ($3,000 per person) if applicable.
Lifetime Maximum Benefit $5,000,000
$2,000,000 calendar year maximum
$5,000,000
$2,000,000 calendar year maximum
$5,000,000
$2,000,000 calendar year maximum
$5,000,000
$2,000,000 calendar year maximum
$5,000,000
$2,000,000 calendar year maximum
$5,000,000
$2,000,000 calendar year maximum
Hospital Admission Deductible NA NA NA NA NA First hospital admission only per person, per year $3,000
Inpatient & Outpatient Hospital Services 10% of negotiated fee 20% of negotiated fee 30% of negotiated fee 30% of negotiated fee 40% of negotiated fee 50% of negotiated fee
Emergency Room Deductible $1003 $1003 $1003 $1003 $1003 $1003
Office Visits $10 copay4 per visit $15 copay4 per visit $25 copay4 per visit $25 copay. First 6 in-network visits (combined with in-network mental and nervous outpatient visits) per calendar year are not subject to the deductible. $35 copay4 per visit $45 copay4 per visit
Preventive (ages 7 and up)
1 Physical per year
Deductibles do not apply
$10 copay, then plan pays up to $250, you pay the balance (if any) at 10% of negotiated fee $15 copay, then plan pays up to $250, you pay the balance (if any) at 20% of negotiated fee $25 copay, then plan pays up to $250, you pay the balance (if any) at 30% of negotiated fee $25 copay, then plan pays up to $250, you pay the balance (if any) at 30% of negotiated fee $35 copay, then plan pays up to $250, you pay the balance (if any) at 40% of negotiated fee $45 copay, then plan pays up to $250, you pay the balance (if any) at 50% of negotiated fee
Well-Baby Care (ages 0-6)
Deductibles do not apply
$10 copay per visit, then 10% of the negotiated fee $15 copay per visit, then 20% of the negotiated fee $25 copay per visit, then 30% of the negotiated fee $25 copay per visit, then 30% of the negotiated fee $35 copay per visit, then 40% of the negotiated fee $45 copay per visit, then 50% of the negotiated fee
Prescription Drugs Annual Deductible (combines in-/out-of-network charges) $150 per person5
Applies to brand-name drugs only
$300 family aggregate
$150 per person5
Applies to brand-name drugs only
$300 family aggregate
$150 per person5
Applies to brand-name drugs only
$300 family aggregate
$150 per person5
Applies to brand-name drugs only
$300 family aggregate
$150 per person5
Applies to brand-name drugs only
$300 family aggregate
$150 per person5
Applies to brand-name drugs only
$300 family aggregate
Prescription Drug - Retail
Generic

Brand if no generic is available

Brand if generic is available
(There is no out-of-network mail order pharmacy benefit)
$15 copay

$25 or 20% of the negotiated fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand name and the generic equivalent
$15 copay

$25 or 20% of the negotiated fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand name and the generic equivalent
$15 copay

$25 or 20% of the negotiated fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand name and the generic equivalent
$15 copay

$25 or 20% of the negotiated drug fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand and generic equivalent
$15 copay

$25 or 20% of the negotiated fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand name and the generic equivalent
$15 copay

$25 or 20% of the negotiated fee, whichever is higher
-or-
$15 copay, plus the cost difference between brand name and the generic equivalent
Prescription Drug - Mail Order
Generic

Brand if no generic is available

Brand if generic is available
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
$20 copay

$30 or 20% of the negotiated fee, whichever is higher

$20 copay, plus the cost difference between the generic drug and the brand drug
Self-injectable drugs
(excluding insulin)
(Retail or mail order)
No copay
30% of negotiated fee
No copay
30% of negotiated fee
No copay
30% of negotiated fee
No copay
30% of negotiated fee
No copay
30% of negotiated fee
No copay
30% of negotiated fee
Mental & Nervous Inpatient 10% of negotiated fee 20% of negotiated fee 30% of negotiated fee 30% of negotiated fee 40% of negotiated fee 50% of negotiated fee
Mental & Nervous Outpatient $10 copay $15 copay $25 copay $25 copay7 $35 copay $45 copay
Substance Abuse Inpatient 10% of negotiated fee; maximum 30 days per year 20% of negotiated fee; maximum 30 days per year 30% of negotiated fee; maximum 30 days per year 30% of negotiated fee; maximum 30 days per year 40% of negotiated fee; maximum 30 days per year 50% of negotiated fee; maximum 30 days per year
Substance Abuse Outpatient $10 copay; maximum 25 visits per year $15 copay; maximum 25 visits per year $25 copay; maximum 25 visits per year $25 copay; maximum 25 visits per year $35 copay; maximum 25 visits per year $45 copay; maximum 25 visits per year

Note: Where a maximum number of visits per year/per day is indicated, it includes both in-network and out-of-network services.

1. Payments to out-of-network providers are based on negotiated fees (or UCR for the Protect 10 Plan). You pay any charges in excess of these fees.
2. UCR = Usual, Customary and Reasonable
3. Waived if admitted
4. Copays do not apply toward satisfaction of the annual deductible or out-of-pocket maximum
5. Rx deductible is not integrated with the medical deductible
6. Customary & Reasonable
7. Deductible does not apply to first 6 in-network visits (includes visits to physicians) per calendar year

This chart is not a contract. Please refer to each plan's Medical Plan Document and Disclosure Form or Certificate.

 

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Protect HSA plans are self-funded High Deductible Healthcare Policies (HDHPs) offered through the Group Insurance Trust of the California Society of CPAs. The Protect HSA plans, when paired with a Health Savings Account offered through a bank, brokerage or other financial institution, provides security against catastrophic medical expenses, while allowing you to set aside pre-tax dollars to pay for qualified medical expenses. For detailed information on HSAs, visit the official government site at http://www.treas.gov/offices/public-affairs/hsa/.

 

As with the ProtectPlus copay plans, the Protect HSA plans have contracted with Blue Cross of California to use its comprehensive provider network and to process our claims. You will have the freedom to choose virtually any health care provider and no physician referral is required. It's up to you whether you go in-network and receive a higher benefit (after your deductible is satisfied) or go out-of-network and pay more. However, when you choose participating network providers, you will take advantage of negotiated rates, which lowers out-of-pocket expenses.

 

You May Offer More Than One ProtectPlus Plan

Although most employers will elect to offer a single plan, your firm may elect to enroll in the ProtectPlus HSA plan and any or all of the ProtectPlus copay plans.

 

This benefit information sheet is not a contract and does not replace the master policy or the plan brochure. It is as accurate as possible, but we cannot be responsible for any errors and make no warranty of any kind.

 

HSA Eligible Plans
In-Network Benefits
Benefit Description HSA-$1,500 HSA-$2,850
Annual Deductible1 $1,500 per member
$3,000 family aggregate
$2,850 per member
$5,650 family aggregate
Annual Out-of-Pocket Maximum $4,500 per member
$9,000 family aggregate
$5,500 per member
$11,000 family aggregate
Lifetime Maximum Benefit $5,000,000
($2,000,000 Calendar year max.)
$5,000,000
($2,000,000 Calendar year max.)
Office Visits 30% of negotiated fee 30% of negotiated fee
Other Professional Services 30% of negotiated fee 30% of negotiated fee
Emergency Care 30% of negotiated fee 30% of negotiated fee
Inpatient Hospital Services and Surgical Facilities 30% of negotiated fee 30% of negotiated fee
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits 30% of negotiated fee 30% of negotiated fee
Other Professional Services 30% of negotiated fee 30% of negotiated fee
Outpatient Surgical Facility 30% of negotiated fee 30% of negotiated fee
Outpatient Preventive Care (Annual Physical Examination) 30% of negotiated fee 30% of negotiated fee
Well Woman Care 30% of negotiated fee,
1 visit/year
30% of negotiated fee,
1 visit/year
Well Baby Care 30% of negotiated fee 30% of negotiated fee
Inpatient Nervous and Mental 30% of negotiated fee 30% of negotiated fee
Outpatient Nervous and Mental Professional Services Day Care 30% of negotiated fee 30% of negotiated fee
Inpatient Substance Abuse 30% of negotiated fee,
max. 30 days/year
30% of negotiated fee,
max. 30 days/year
Outpatient Substance Abuse 30% of negotiated fee,
max. 25 visits/year
30% of negotiated fee,
max. 25 visits/year
Physical Therapy, Occupational Therapy, Chiropractic Care 30% of negotiated fee,
25 visits/year
30% of negotiated fee,
25 visits/year
Acupuncture 30% of negotiated fee.
Plan pays up to $60/visit,
max. 12 visits/year
30% of negotiated fee.
Plan pays up to $60/visit,
max. 12 visits/year
Durable Medical Equipment 30% of negotiated fee 30% of negotiated fee
Skilled Nursing Facility 30% of negotiated fee,
100 days/year
30% of negotiated fee,
100 days/year
Hospice Care 30% of negotiated fee,
up to the $5,000 lifetime max.
30% of negotiated fee,
up to the $5,000 lifetime max.
Home Healthcare 30% of negotiated fee,
90 visits/year
30% of negotiated fee,
90 visits/year
Prescription Drugs
Prescription Deductible1 No separate deductible No separate deductible
Participating Pharmacies (30-day supply) 30% of negotiated drug fee 30% of negotiated drug fee
Self-Administered Injectable Drugs (excluding Insulin)
Retail (30-day supply)
Mail Order (60-day supply)
30% of negotiated drug fee 30% of negotiated drug fee
Mail Order (60-day supply) 30% of negotiated drug fee 30% of negotiated drug fee
Out-of-Network Benefits
Annual Deductible1 No separate deductible, Out-of-Network benefits are included in the annual deductible
Annual Out-of-Pocket Maximum No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.
Office Visits 50% of negotiated fee 50% of negotiated fee
Inpatient Hospital Services - Contracting Hospital 50% of negotiated fee,
up to a max. of $540 per day
50% of negotiated fee,
up to a max. of $540 per day
Mental and Nervous - Inpatient 50% of negotiated fee 50% of negotiated fee
Outpatient Plan pays up to $30 per visit,
max. 25 visits/year
Plan pays up to $30 per visit,
max. 25 visits/year
Substance Abuse - Inpatient 40% of negotiated fee,
max. 30 days/year
40% of negotiated fee,
max. 30 days/year
Outpatient 40% of negotiated fee,
max. 25 visits/year
40% of negotiated fee,
max. 25 visits/year
Prescription Drugs
Prescription Deductible No separate deductible No separate deductible
Outpatient Prescription Drugs - Non-Participating Pharmacies 50% of the negotiated drug fee 50% of the negotiated drug fee
Self-Administered Injectable Drugs (excluding Insulin) 30% of negotiated fee plus any excess charge where self-injectable drug price exceeds negotiated drug fee 30% of negotiated fee plus any excess charge where self-injectable drug price exceeds negotiated drug fee

Note: Annual Out-of-Pocket Maximum includes Annual Deductible. Family Aggregate: Once one or more family members eligible covered expenses (combined) meet this amount, the requirement is satisfied for all covered family members.

1 Annual Deductible is combined, In- and Out-of-Network. The co-insurance applies after the deductible has been satisfied.

 

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  • Because our members value choice, they have partnered with Blue Cross of California to offer two of its CaliforniaCare HMO plans. CaliforniaCare differs from ProtectPlus in that it is a fully-insured plan through Blue Cross of California. Blue Cross determines the rates and benefits and sets underwriting and administration policy. Some plan features offered by the ProtectPlus plans are not available to participants in the CaliforniaCare HMO plans, including rights of survivorship, availability to Solo Practitioners, and multiple plan selection. Your firm may offer only one of the HMO plans; however, you can pair a CaliforniaCare HMO plan with any, or all, of the ProtectPlus copay and HSA plans.
  • All CaliforniaCare HMO Plans Provide:
    • Access to quality healthcare through the Blue Cross network of CaliforniaCare HMO healthcare providers.
    • Coverage for mental health and substance abuse services.
    • Comprehensive coverage for a wide range of healthcare services.
    • Emergency care coverage worldwide, 24 hours a day.
    • Simplified procedures - no claim forms to fill out.
    • Customer services exclusively dedicate to CalCPA CaliforniaCare members
  • The CaliforniaCare Network
    CaliforniaCare HMO network has contracted with more than 32,000 physicians and more than 370 hospitals throughout the state. When enrolling in this plan, you choose a doctor for yourself (and for each enrolled family member) from a Participating Medical Group (IPG) or Independent Practice Association (IPA) in the network. The doctor you choose is called your Primary Care Physician, and this doctor is responsible for managing your healthcare needs. Generally, Primary Care Physicians specialize in internal medicine, general practice, family practice or pediatrics.
  • You simply call your Primary Care Physician when you need medical care. Also women may go to an OB/GYN in the network without a referral. To receive plan benefits for care provided by other specialists, you will need a referral from your PMG or IPA before you receive the service. This includes hospitalization, except in emergencies.

 

Blue Cross CaliforniaCare (HMO) Plans
Benefit Description HMO 100%
HMO 80%
Annual Deductible

None

None
Annual Out-of-Pocket Maximum $1,750 Individual
$3,500 Family
$5,000 Individual
$10,000 Two-Party
$15,000 Family
Professional Services
Office Visits $10 per visit $15 per visit
Specialist & Consultants $10 per visit $30 per visit
Hospital
Emergency Care
Co-pay waived if admitted
$100 per visit $100 per visit
Inpatient Hospital Services and Surgical Facilities No charge 20% of charges
Other Professional Services No charge 20% of charges
Outpatient Medical Services No charge No copay
Health Maintenance
Outpatient Annual Physical Examination, Well Woman and Well Baby Care $10 per exam $15 per exam
Mental and Nervous
Inpatient Nervous and Mental Not covered* Not covered*
Outpatient Nervous and Mental
(Professional Services Day Care
(1 visit/day & 20 visits/12-month period))
1 visit per day, 20 visits per year
$10 per visit $35 per visit
Inpatient Substance Abuse
(acute phase only)
No charge $100 per day plus 20% of charges
Outpatient Substance Abuse Not covered Not covered
Other Services
Home Health Care
(90 visits per year)
No charge $15 per visit
Physical Therapy, Occupational Therapy, Chiropractic Care
(60-day period of care)
No charge $15 per visit
Prescription Drugs
Prescription Drug Deductible $150 Brand Deductible per member $150 Brand Deductible per member
Participating Pharmacies
(30-day supply)
$10 Generic
$20 Brand Name (if generic not available)
Brand if Generic is available: $10 plus the difference in cost between brand and generic, after deductible has been satisfied.
$10 Generic
$20 Brand Name (if generic not available)
Brand if Generic is available: $10 plus the difference in cost between brand and generic, after deductible has been satisfied.
Mail Order (60-day supply) $10 Generic
$20 Brand Name (if generic not available)
Brand if Generic is available: $10 plus the difference in cost between brand and generic, after deductible has been satisfied.
$10 Generic
$20 Brand Name (if generic not available)
Brand if Generic is available: $10 plus the difference in cost between brand and generic, after deductible has been satisfied.

Note: This summary is a brief review of benefits. It is not a contract and does not replace the master policy. It is as accurate as possible, but we cannot be responsible for any errors and make no warranty of any kind.

*These limitations, co-pays and benefit maximums do not apply to severe mental disorders as defined in California state law (other than primary substance abuse or developmental disorder). Severe mental disorders are subject to the same co-pays and benefit maximums applicable to other medical conditions for covered services. In order or receive coverage, services must be rendered by a Blue Cross behavioral health provider.

 

  • You May Mix and Match Your Healthcare Plans
    Although most employers will elect to offer a single plan, your firm may elect to enroll in and offer any combination of ProtectPlus copay, ProtectPlus HSA and CaliforniaCare HMO plans. However, if the firm wishes to include an HMO option, only one of the CaliforniaCare HMO plans may be offered.

 

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  • Employer Eligibility
    ProtectPlus is available to accounting firms and firms offering general financial services. To be eligible and retain such eligibility, more than 50% of all the Employer's owners (i.e., principals, proprietors, partners, shareholders or other owners) must be CPAs or Associate members of CalCPA in good standing. If you are a CPA and not a member of CalCPA, click here to see how you can join. All employers deemed to be part of an affiliated group under Internal Revenue Code Sections 414 (b), (c), or (m) are considered to be a single employer. Solo practitioners (a CPA practicing on his/her own with no other employees) are eligible to apply.
  • Employee Eligibility
    Active, regular full-time employees working at least 20 hours per week are eligible for coverage. If a husband and wife are employed by the same employer, they may both be covered as Employees.
  • Dependent Eligibility
    Eligible dependents include a lawful spouse, domestic partner, and unmarried children of eligible employees, up to age 19, or through age 24 if the child is an unmarried, full-time student carrying nine or more credit hours per semester. Disabled children of eligible employees who, with appropriate medical certification, are eligible for coverage at any age. Children of domestic partners are eligible. Non-student dependent children, ages 19 through 24, are eligible but must be covered at employee rates.
  • Participation Requirements
    If the employer pays 100% of the premiums, or if the plan covers three or fewer employees, then 100% of eligible employees must be covered. Otherwise, at least 75% of the individuals eligible for coverage in each firm must apply for that firm's coverage.
  • If the employer is paying 100% of the employee premium, then all eligible employees must enroll. If the employee pays part of the premium, a minimum of 75% of the eligible employees must enroll. Employees who waive coverage on the grounds that they have other group coverage are not counted as eligible employees. 1099 employees are not eligible.

 

 

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