Access Benefits

Benefit

Bronze

Silver

Gold

Frequency Limits

Physicians Office Visits

$50 per visit

$75 per visit

$100 per visit

3 per insured/year; 6 per family/year

Diagnostic X-Ray
and Lab Tests

$50 per visit

$75 per visit

$100 per test

3 per insured/year; 6 per family/year

Health Screening

$50 per visit

$75 per test

$100 per test

Up to 3 tests per insured/year

Well Child Care

$50 per visit

$50 per visit

$50 per visit

Up to 6 visits/year

Emergency Room

$50 per visit

$100 per visit

$150 per visit

Up to 4 visits/year

Hospital Admission

$250 per admission

$400 per admission

$750 per admission

Daily Hospital Confinement

$250 per day

$400 per day

$750 per day

Up to first 30 days of confinement

Intensive Care Unit

$250 per day

$400 per day

$750 per day

Up to first 30 days of confinement

Surgery

25% of amount in schedule of operations

50% of amount in schedule of operations

50% of amount in schedule of operations

Anesthesia

25% of amount in schedule of operations

50% of amount in schedule of operations

50% of amount in schedule of operations

Prescription Drug

$5 per script

Up to 5 scripts per year

Access Specific Benefits

Benefits

Covered by all Plans

Frequency Limits

Ambulance

$50

Up to 2/year

Transportation
(Ground & Air)

$100

Up to 3 round trips per year

Lodging

$25 per day

2 days/occurrence; $3,000 Calendar Year Max

Diabetes Supplies, Equipment and Self Management

$100

1/year

Mammogram Screening

$100 per screening

Counts towards number of annual tests

Cervical Cytology Screening

$100 per screening

Counts towards number of annual tests

Prostate Cancer Screening

$100 per screening

Counts towards number of annual tests

Second Surgical Opinion

$100 per visit

2 visits/year

Prosthesis

$250 per covered accident

Second Medical Option for Cancer Diagnosis

$100 per visit

End of Life Care

$25 per day

60 days

Home Health Care

$25 per visit

40 visits

Outpatient Chemical Abuse & Dependence Treatment

$25 per visit

Up to 60 visits per year

Outpatient Mental, Nervous or Emotional Disorders

$25 per visit

Up to 20 visits/year for mental health

Ambulatory Surgical Center

$50 per visit

Up to 4 visits/year

Accidental Death

$5,000

Enhanced Benefits

Benefits

Bronze

Silver

Gold

Frequency Limits

Physicians Office
Visits

$50 per visit

$100 per visit

$150 per visit

3 per insured/year; 6 per family/year

Diagnostic X-Ray
and lab tests

$50 per test

$100 per test

$250 per test

3 per insured/year; 6 per family/year

Health Screening

$50 per test

$150 per test

$250 per test

Up to 3 tests per insured/year

Well Child Care

$50 per visit

$100 per visit

$250 per visit

Up to 6 visits/year

Emergency Room

$50 per visit

$150 per visit

$250 per visit

Up to 4 visits/year

Hospital Admission

$250 per admission

$750 per admission

$1,000 per admission

Daily Hospital Confinement

$200 per day

$400 per day

$750 per day

Up to first 30 days of confinement

Intensive Care Unit

$250 per day

$750 per day

$1,000 per day

Up to first 30 days of confinement

Surgery

100% of amount in schedule
of operations

250% of amount in schedule
of operations

500% of amount in schedule
of operations

Anesthesia

25% of amount

50% of amount in schedule
of operations

50% of amount in schedule
of operations

Prescription Drug

$5 per script

$10 per script

$15 per script

Up to 5 scripts/year

Enhanced Specific Benefits

Benefits

Bronze

Silver

Gold

Frequency Limits

Sickness & Non-Occupational Accident Disability Income

N/A

$250 p/wk; 7 day elimination period; 13 week duration

$400 p/wk; 7-day elimination period; 26 week duration

Outpatient Ambulatory Care

N/A

$150 per visit

$250 per visit

Up to 4/year

Ground Ambulance Benefit

$150 per use

$250 per use

$250 per use

Up to 4/year

Transportation Benefit

$100 per trip

Air - $500; Other $250

Air - $1,000; Other $250

Up to 3 round trips/year; $3,000 annual max

Lodging

$25/day; 2 day max./occurrence

$100/day; 10 day max./occurrence

$100/day; 10 day max./occurrence

$3,000 annual max./occurrence

Diabetes Supplies, Equipment and Self-Management

$100

$250

$1,000

1/year

Mammogram Screening

$100 per screening

Counts towards number of annual tests

Cervical Cytology Screening

$100 per screening

Counts towards number of annual tests

Prostate Cancer Screening

$100 per screening

Counts towards number of annual tests

Second Surgical Opinion

$100 per visit

2 visits/year

Prosthesis

$250 per covered accident

Second Medical Option for Cancer Diagnosis

$100 per visit

End of Life Care

$25 per day

60 days

Home Health Care

$25 per visit

40 visits

Outpatient Chemical Abuse and Dependence Treatment

$25 per visit

Up to 60 visits/year

Outpatient Mental, Nervous or Emotional Disorders

$25 per visit

Up to 20 visits/year for Mental Health

Ambulatory Surgery Center

$50 per visit

Up to 4 visits/year

Accidental Death

$5,000

$5,000

Participating Beech Street Network Providers offer LBHP participants up to a 40% discount on their standard rates or fees.

Example:
Standard Doctor's visit rate: $100
40% Beech Street Discounted rate :$60
LBHP Plan Benefit Paid: $50
Out of Pocket expense for LBHP Participant: $10

For more information, please visit Beech Street's Network Services page.

Flex Shield Access Rates (NY Only)
Rate Indications (Monthly Rates)

1. As an employer, can I just pay only for a portion of my employee’s individual monthly premium even if they want to cover their spouse and/or family?

A. Yes, we can set up the premiums so that the Employer pays the Employed Enrollee coverage and the Employed Enrollee pays for spouse or dependent coverage.

2. As an employer, can I adjust the amount I’m contributing to my employee’s premium either annually or based on length of service?

A. You can change your percentage of contribution to the plan on an annual basis at policy renewal but not during the term of the policy or per employee. 

3. The maximum for daily hospital confinement is $30K.  A surgery and subsequent 3 day hospital confinement can often exceed $75K.  Is there another plan that would cover the difference? 

A. LBHP has a limit of $1,000 p/day for hospital confinement with a maximum of $30K.  In order to receive the full $30K the patient would have to be in the hospital for 30 days at $1,000 p/day.  There is coverage for surgery of up to $2,000 per scheduled amount as well.  In this scenario benefits would be paid for up to $5,000 ($3,000 per hospital confinement at $1,000 p/day for 3 days plus up to $2,000 for surgery).

4. If I am an enrollee in LBHP through my employer and have a comprehensive health plan through my employer as well, would LBHP still pay benefits in addition to my comprehensive plan?

A. Yes, LBHP would pay in addition to your comprehensive plan.  For example if you go to the doctor through your comprehensive plan and pay a $25 co-pay for that visit, LBHP would pay $50 for that visit, so you would get your $25 co-pay back plus an additional $25.

5. If I am an enrollee in LBHP through my employer, can I also open a Heath Savings Plan (HSA)?

A. An individual is eligible to have an HSA if they DO have a high-deductible health plan (HDHP) and they DO NOT have certain other kinds of coverages in addition to that HDHP. 

6. As an employer, what is the minimum group size for eligibility?

A. The program requires a minimum of 10 enrolled employees in order to be eligible.  Employer organizations with less than 10 enrolled employees can still participate in the program as a participating organization in a Master Policy we’ve created, however, the employer must contribute at least 50% of the enrolled employee’s monthly premium in this circumstance.

In NY there is a requirement for a minimum of 10 enrolled employees.  In addition, the organization MUST have at least 50 eligible employees to participate in LBHP. NY employers that do not meet the above requirements are ineligible for coverage and cannot participate in the Master Policy option.