HMO Plans

• PPO Plans
• Standard & Basic PPO Plans
• Dental Plan

The CHIP Standard HMO Plan (in network only)

• Deductible - None
• Copayments:

• $15 physician visits
• $50 emergency room
• $100 inpatient hospital per admission
• $50 outpatient hospital
• $20 spinal manipulation

• Out of Pocket $2,000 individual/$4,500 family
• Prescriptions $10 generic/$20 brand name

The CHIP Basic HMO Plan (in network only)

• Deductible - None
• Copayments:

• $20 physician visits
• $200 emergency room
• $850 inpatient hospital per admission
• $150 hospital outpatient
• $20 spinal manipulation

• Out of Pocket $3,000 individual/$6,000 family
• Prescriptions $20 generic/$35 brand name/$50 non-formulary

The CHIP Plus HMO Plan (in network only)

• Deductible - None
• Copayments:

• $10 physician visits
• $50 emergency room
• $250 inpatient hospital per admission
• $50-$75 hospital outpatient

• Out of Pocket $2,000 individual/$4,500 family
• Prescriptions $10 generic/$15 brand name

The CHIP Point of Service HMO Plan (in network and out of network)

In Network

• Same as the Standard HMO Plan

Out of Network

• Deductible $300 individual $600 family
• Physician visits coinsurance of 30% after ded.
• Emergency room coinsurance of 30% after ded.
• Inpatient Hospital coinsurance of 30% after ded.
• Outpatient Hospital coinsurance of 30% after ded.
• Out of Pocket $2,300 individual/$5,100 family
• Prescriptions coinsurance of 30%
(after separate prescription deductible of $100 individual/$200 family).

Important notes:

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

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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