Standard & Basic PPO Plans

• HMO Plans
• PPO Plans
• Dental Plan

The CHIP Standard PPO Plan
(in Network)

• Deductible $300 individual/$900 family
• Coinsurance 20% of 1st $6,000 individual/20% of 1st $12,000 family
• Physician office visits paid at 80% after ded.
• Emergency room paid at 80% after ded.
• Inpatient hospital paid at 80% after ded.
• Outpatient hospital paid at 80% after ded.
• Out of pocket $1,500 (includes deductible) individual/$3,300 (includes deductible) family
• Prescriptions paid at 50% after deductible

(Out of Network)

• Deductible $600 individual/$1,800 family
• Coinsurance 50% of 1st $10,000 individual/50% of 1st $20,000 family
• Physician office visits paid at 50% after ded.
• Emergency room paid at 80% after ded.
• Inpatient hospital paid at 50% after ded.
• Outpatient hospital paid at 50% after ded.
• Out of pocket $5,600 (includes deductible) individual/$11,800 (includes deductible) family
• Prescriptions paid at 50% after deductible

The CHIP Basic PPO Plan
(In Network)

• Deductible $750 individual/$2,250 family
• Coinsurance 30% of 1st $10,000 individual/30% of 1st $20,000 family
• Physician office visits paid at 70% after ded.
• Emergency room paid at 70% after ded.
• Inpatient hospital paid at 70% after ded.
• Outpatient hospital paid at 70% after ded.
• Out of pocket $3,750 (includes deductible) individual/$8,250 (includes deductible) family
• Prescriptions paid at 50% after deductible
• Out of Network
• Deductible $1,500 individual/$4,500 family
• Coinsurance 50% of 1st $10,000 individual/50% of 1st $20,000 family
• Physicians office visits paid at 50% after ded.
• Emergency room paid at 70% after ded.
• Inpatient hospital paid at 50% after ded.
• Outpatient hospital paid at 50% after ded.
• Out of pocket $6,500 (includes deductible) individual/$14,500 (includes deductible) family
• Prescriptions paid at 50% after deductible

Important notes:

Groups of 2-50 are guarantee issue and must provide the most current Colorado State Unemployment Insurance Tax Report (UITR).

All new business "group applications" must be in by the 15th of the month prior to the requested effective date.

All supporting documents, such as payments, employee applications, waivers, UITRs, etc. must be submitted by the 25th of the month prior to the effective date.

After the 15th, forms are required for all new groups that do not have all supporting documents submitted by the 15th. Note: the group application must still be submitted by the 15th, even if it is not complete.

Dental group applications and all supporting documents must be submitted 30 days prior to the effective date, or they will automatically be processed for the next month.

New business documents that do not meet these guidelines will not be approved for the requested effective dates, but may be reconsidered for the following month.

Groups of 1 applying for guarantee issue (basic and standard plans only) must be submitted with all of the required documentation by the 15th of the month prior to the requested effective date. Guarantee issue will be considered on groups of one if:

Applying within 31 days following birthday and include:

Three most recent years tax returns
Proof of employee’s birthday
Groups and employee applications

Groups of 1 applying for coverage and not qualified for guarantee issue will be underwritten and if accepted the coverage will be effective the 1st of the month after approval.


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