Anthem Gold Pathway X PPO 1250/10 Plan Review

Anthem Gold Pathway X PPO 1250/10 Plan Review

June 15, 2015

So you've been researching health insurance plans in Ohio for what feels like three and half life times, even though it's probably only been a couple weeks.

Your search has led you to this plan from Anthem Blue Cross Blue Shield and you want to know as much as you can about it before you put it in charge of covering you and/or your family.

Well, I just might be able to help you out with that.

Even though Anthem would win hands down the award for worst, most complicated and confusing health insurance plan names, we are going to do our best today to move past that and go as in-depth as possible to make sure you know everything you need or want to know.

Click here to view the summary of benefits for the Gold Pathway X plan and follow along (Page 25).

Network Name

Anthem has taken one of the more daunting aspects of health insurance and made it worse.

They made some of the craziest, possibly questionable, changes to their networks of any insurance company out there.

The Pathway X portion of the plan name indicates the name of the network you are getting with the plan, regardless if you know that or not.

Once you have the cipher to crack the code for Anthem's naming structure, you can actually glean a lot of information just from the name.

The X in Pathway X is short for Exchange or Health Insurance Exchange.

I promise I'll stop beating the dead horse that is name of this plan soon, but exchange is not even what they are called anymore as it has been renamed the Health Insurance Marketplace and even more confusing you have to go to to buy from the Health Insurance Marketplace.

That last part isn't Anthem's fault, that's the federal government's misstep, but it felt appropriate to keep terrible name train going and mention that here.

The sad part is everything I've just said isn't how Anthem made the network experience even more daunting.

It's the two words tired hospital after Pathway X that will make your head want to explode.

Just know that you will want to do everything you can to make sure you are going to a tier 1 hospital.

Plan Includes Non-Network Coverage? Yes

If you happen to find yourself at a hospital that isn't in the tier 1 or 2 portions of Anthem's network you will still be covered, you just will be required to a pay a lot more for that treatment.

Deductible (Network/Non-Network)

For a single person you will be on the hook for $1,250 in-network and $5,000 out-of-network.

For a family (two or more people) you will pay $2,500 or $10,000.

These numbers are simply the dollar amount you have to cover first before the co-insurance kicks in. We'll talk about what co-insurance is in a little bit.

Out-Of-Pocket Limit (Network/Non-Network)

This is the most important number you want to pay attention to on any policy you look at.

The most you will pay of any covered in-network service during the calendar year is $3,100 for a single person. For a family it's $6,200. If you are out-of-network it will go all the way up to $10,000 and $20,000.

Co-Insurance (Network/Non-Network)

Once you've paid your deductible, Anthem is going to split the bills with you 90/10. That means they will 90 percent of the bill and you will be left with only 10 percent in-network.

Non-network treatment will be a 60/40 split.

For example, if you have a $3,000 CT scan you will pay the first $1,250 which takes care of your deductible and then you will split the remaining $1,750 with Anthem at 90/10. In this case you would pay $175 and Anthem would pay $1,575. Not a bad deal.

Office Visit Copays

If you just need checked out by your primary care doctor than you will have a $30 unlimited copay.

If you need to something a little more specific and a trip to a specialist is in order, then you actually won't have a copay for this and instead the visit will go towards your deductible and then into the co-insurance.

Outpatient Diagnostic Tests

This can include stuff like x-rays or EKG's and will be subject to your deductible then split through the co-insurance.

Once you've hit both limits, you won't have to pay for any in-network treatment for the rest of the year.

Outpatient Advanced Diagnostic Tests

Anthem is getting a little fancy here and making a distinction between the two, even though they are going to be covered the same way. Most policies don't make this specific of a distinction.

However, test like these would include things like MRI's and CT scans. They would also be subject to your deductible and then split through co-insurance.

Preventative Care

All services outlined by the Affordable Care Act (ACA) or Obamacare will be covered at “no additional cost to you” which essentially means free.

Urgent Care

How these next three items are covered feels a little stiff to me, but here it goes.

If you need to make a late night visit to your closest network urgent care, the visit will be subject to the deductible, than a $50 copay and finally you 10 percent share of the co-insurance.

I've never seen a benefit structured like this as anytime a copay is involved your deductible and co-insurance are not a factor, but somehow Anthem found a way to hit the trifecta.

Emergency Room Care

Like the urgent care visit you have to pay toward your deductible first, then pay a $200 copay and again finally round things out with the 10 percent co-insurance if necessary.

Much like the hospital networks we talked about early, this is definitely making things harder and more confusing than need be.

Hospital Inpatient Admission

Finishing up the slightly bizarre coverage trio. If you find yourself in the hospital overnight or longer you have to again pay your deductible, then a $500 copay and once again your 10 percent co-insurance for tier 1. For tier 2 your co-insurance jumps to 40 percent.

Hospital: Outpatient Surgery Hospital Facility

Even though we've managed to escape the unnecessarily complicated section of this health insurance policy the tired network system still haunts us.

If you having a quick and easy surgery done at a hospital location it will be subject to your deductible then 10 percent co-insurance for tier 1 and 40 percent co-insurance for tier 2.

Retail Pharmacy Deductible

I might have spoke too soon when I said things were going to get less complicated.

Anthem has broken your medications down into four tiers. The first two are just going to have a flat copay assigned to them.

Tier 1 - $15
Tier 2 - $40

However, tier's three and four will have to be paid to your deductible than co-insurance.

Make you read the fine print for this benefits and others in the policy by viewing the summary of benefits.

Dental and Vision

Both pediatric dental and vision will be covered under this plan. However, if you are 19 or older it will not and you will have to added those coverages for an extra cost.

Mental Health and Substance Abuse: Outpatient Facility and Services

If you require and treatment of therapy related to these conditions you have to pay to your deductible first and co-insurance.

Physical Occupational and Speech Therapy

You will have coverage for these services but for only 20 visits a year per type of therapy. You will again have to pay toward your deductible then into the co-insurance.

The Bottom Line

Anthem has obviously structured this plan a little different than you might have seen from other health insurance companies.

Are they deal breakers, probably not. But that will largely depend on you situation and what's important to you.

At the very least, they will definitely be a good tie breaker in favor of any other company.

Next Steps

Let's compare some different options and see what some of the tie breakers would be.