PPO Plans

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

The CHIP $15-$250 PPO Plan
(in Network)

• Deductible - None
• Copayments:

• $15 physician visits
• $15 chiropractic visits
• $100 emergency room
• $250 inpatient hospital plus 10% coinsurance
• $250 outpatient hospital plus 10% coinsurance

• Out of Pocket $1,000 + copayments individual/$3,000 + copayments family
• Prescriptions $15 generic/$25 brand name/$40 non formulary

The CHIP $15-$250 PPO Plan
(Out of Network)

• Deductible $1,000 individual/$3,000 family
• Physician visits coinsurance of 30% after ded.
• Emergency Room $100 copayment per visit
• Inpatient hospital $750 copayment plus 30% coinsurance
• Outpatient hospital $750 copayment plus 30% coinsurance
• Out of Pocket $3,000 + deductible & copayments individual/$9,000 + deductible and copayments family
• Prescriptions must use a participating pharmacy

The CHIP $15-$500 PPO Plan
(in Network)

• Deductible None
• Copayments

• $15 physician visits
• $100 emergency room
• $500 inpatient hospital plus 20% coinsurance
• $500 outpatient hospital plus 20% coinsurance

• Out of pocket $2,000 + copayments individual/$6,000 + copayments family
• Prescriptions $15 generic/$25 brand name/$40 non formulary

(Out of Network)

• Deductible $1,500 individual/$4,500 family
• Physician visits coinsurance of 40% after ded.
• Emergency room $100 copayment per visit
• Inpatient hospital $1,500 copayment plus 40% coinsurance
• Outpatient hospital $,500 copayment plus 40% coinsurance
• Out of pocket $6,000 + deductible & copayments individual/$18,000 + deductible & copayments family
• Prescriptions must use a participating pharmacy

The CHIP $25-$500 PPO Plan
(in Network)

• Deductible None
• Copayments:

• $25 physician visits
• $100 emergency room
• $500 inpatient hospital plus 20% coinsurance
• $500 outpatient hospital plus 20% coinsurance

• Out of Pocket $2,000 + copayments individual/$6,000 + copayments family
• Prescriptions $15 generic/$25 brand name/$40 non formulary

(Out of Network)

• Deductible $2,000 individual/$6,000 family
• Physician visits coinsurance of 40% after ded.
• Emergency room $100 copayment per visit
• Inpatient hospital $1,500 copayment plus 40% coinsurance
• Outpatient hospital $1,500 copayment plus 40% coinsurance
• Out of pocket $6,000 + deductible & copayments indivdual/$18,000 + deductible & copayments family
• Prescriptions must use a participating pharmacy

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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