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Chamber of Commerce Plan Benefits/RatesJanuary - December 2024 Highmark Blue Shield of Northeastern New York Small Group Plan Grid Off-Exchange * Common Law employee(CLE) must be enrolledPlatinum PPO Plus Gold Radius High GOLD Blended RadiusSILVER POS 8000 HSA QualifiedNetworkPPO POS POS POS Single$1,198.80$978.90$897.91$756.72Double$2,397.61$1,957.80$1,795.82$1,513.44Employee/Child(ren)$2,037.97$1,664.13$1,526.45$1,286.43Family$3,416.49 $2,789.87 $2,559.05 $2,156.66 In-Network Deductible (Single/Family)N/AN/A$1,250/$2,500 $5,500/$11,000CoinsuranceN/AN/A30%0% *Out of Pocket Maximum (Single/Family)$7,000/$14,000 $9,100/$18,200$9,100/$18,200$7,500/$15,000 Out-of-Network Deductible (Single/Family)$5,000/$10,000 $5,000/$10,000$5,000/$10,000$5,000/$10,000Coinsurance50%50%50%50% *Out of Pocket Maximum (Single/Family)$10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 PCP/Specialist$15 / $30 $30 / $50$25 / $50 0% *Preventive Care $0 $0 $0 $0 Inpatient Hospitalization (per admission)$500 $1,00030% *0% *Outpatient Surgery$100 $25030% *0% *Emergency Room$150 $300$350 0% *Urgent Care$75 $75$100 0% *Ambulance$100 $300$350 0% *Telemedicine$0 $0 $0 0% *Pharmacy Co-payment $10 / $35 / $100 $10 / $50 / $100 $10 / $35 / $100 $10 / $35 / $100 *Preventive Drug List Yes Yes Yes YesOpen Enrollment is during November for January 1st coverage. All applications must be received in our office by Wednesday, December 1st. Wellness Card $250 wellness debit card - Benefit allowance accessible through the use of a debit card, at participating providers for exercise centers, fitness clubs, gyms and recreational or sports campsDomestic Partner Coverage for Same or Opposite Sex Routine Vision Exam Coverage is included in all plans. Embedded Plans: Each member will pay towards, but never exceed their individual and/or OOPM until the larger family deductible is met. HSA Contribution Limits Single $3,850 Family: $7,750 Catch-up Contributions (Age 55 or older) $1,00030%$1,891.68$1,607.93$2,695.65$945.84$9,100/$18,200 30% *$1,250/$2,500 $10,000/$20,000 GOLD Blended EX An * asterisk next to a benefit means the DEDUCTIBLE must be met before the plan pays or co-pays are applied.POS/PPO Wrap$5,000/$10,000Pediatric Dental Required by the ACA for dependents under age 19. Pediatric dental is now embedded in all medical plans.Telemedicine, Visit a doctor using your mobile device or computer. Go to DoctorOnDemand.com to get started.Yes$10 / $35 / $100$25 / $50 30% *50% *$100$350$0 Provider Networks for all covered services can change at times throughout the plan year. It is strongly recommended that you search the provider network on each plan before submitting your enrollment and using the plan throughout the year to ensure that your provider of choice is participating in the plan you select. All plans include Emergency service 24/7, anywhere in the world. Point of Service (POS) networks include Out-of-Network providers, but at a higher cost share than In-Network. HMO networks do not include Out-of-Network providers. Exclusive Provider Organizations (EPO) typically includes comprehensive national provider networks.To confirm network providers, visit www.bsneny.com, Find a Doctor link.This is not a complete comparison or contract and in no way details all the benefits, limitations, or exclusions. Rates and terms are subject to change.$350This comparison has been prepared as a guide to assist you in evaluating the program. Monthly premium rates shown do not include administrative fees - Plan summaries are available upon request or online$0Eligibility: To participate in the Chamber's insurance program, businesses must maintain their Chamber Membership. For Small Group eligibility, there must be at least one Common Law Employee (CLE) enrolled. An employee does not include the sole owner or the spouse of the owner. If you do not qualify for a Small Group product, please contact our office for INDIVIDUAL plan options available to Members without a CLE . 2024 PLAN HIGHLIGHTSUpdated: November, 2022 PO Box 1616 Troy NY 12181-1616 For assistance call 518-720.8888