YNHHS Medical Plan

What you need to know

The YNHHS Medical Plan connects you to the world-class care provided by our Signature networks of facilities and providers. Of course, you can also use Anthem PPO or out-of-network providers, but you’ll usually pay more if you do. The medical plan is administered by Anthem Blue Cross and Blue Shield.

Connect with the Signature network
The Signature Network includes: YNHHS hospitals/facilities (owned or jointly owned), Trinity Health of New England owned or jointly owned hospitals/facilities (CT locations only), PCP’s from Community Medical Group (CMG), NEMG, Trinity Health of New England and SoNE HEALTH (CT locations only), WestMed, Yale Medicine (YM), and Specialists from NEMG, YM, CMG, Trinity, and those that have medical staff privileges at a YNHHS facility.

View the Tier 1/Signature Network.

View the Trinity Health of New England facilities. Note: Only CT locations are included in the Tier 1/Signature Network.

Patient Resource Coordinators are available to assist you with your Tier 1/Signature Network needs, such as:

  • Finding a physician,
  • Making an appointment,
  • Signing up for My Chart, and
  • Claims issues.

Contact them by calling 844-543-2147, press option 3.

How the Plan Works

The YNHHS Medical Plan is designed to help keep you and your family healthy. Used in tandem with your other benefits—including care and condition management and coaching services—it’s here to support you when you need care.

  • You’ll pay nothing for preventive care—including some preventive tests and prescription medications—when you use network providers.
  • If you choose a provider in Tier 2, you will have to meet an annual deductible before receiving reimbursement for certain types of services.
  • Behavioral health and substance abuse benefits are included in the medical plan.
  • You only need to meet one combined annual out-of-pocket maximum for medical and prescription drugs. All your copays and coinsurance for covered services are applied toward this maximum.  Once the out-of-pocket maximum is met, the plan pays 100% of eligible expenses for the remainder of the calendar year for each enrolled person.
  • Special rules apply when you or your covered dependents are covered by more than one plan.

You may choose to waive medical coverage if you’re covered by another plan or your spouse is a YNHHS employee.

How much you pay for care depends on the provider or facility you choose:

Signature Network—YNHHS Facilities & Providers
When you use a Signature network provider and facility, you’ll pay less for covered services. You pay a flat copay for care and do not have to pay a deductible before the plan begins to pay benefits.

Note: Some Signature Network providers also provide care at facilities that are not in our health system. If you receive care at these other sites, you will pay higher costs for these facilities. For example, a surgeon who practices at Signature network facilities may also perform surgery at private surgical centers. If your surgery is done at a private center, you would pay the Anthem PPO network or Out-Of-Network rate for the doctor and the facility.

  • You’ll generally pay a flat copay for care when you use Signature network providers and facilities, including:
    • Facilities owned by Yale New Haven Health and Trinity New England
    • Our Signature clinician network of primary care providers and specialists who are credentialed at a facility owned by Yale New Haven Health
    • Connect with the Tier 1/Signature Network
  • Use the links below to search for a YNHHS facility that provides these services:
  • Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.
Anthem PPO Providers

When you choose to receive care from an Anthem Century Preferred Network provider:

  • If you choose a provider in Tier 2, you will have to meet your annual deductible before receiving reimbursement for certain types of services.
  • After you meet your deductible, you’ll generally pay 20% coinsurance or a copay until you reach your annual out-of-pocket maximum.
  • Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.

To find a provider in the Anthem Century Preferred Network, visit the Anthem website or call 888-266-2896. Or download the Anthem Sydney app to find health care services, resources, and important contacts. Learn more about Sydney [PDF].

Out-of-Network Providers
When you use a provider or facility that is not in the Signature or Anthem Century Preferred Network:

No-cost vaccines for you and your dependents
You and your covered dependents can get no-cost vaccines for shingles, pneumonia, flu (ages 18 and older only), COVID-19, tetanus/diphtheria, and hepatitis A and B through the CVS Caremark Broader Vaccination Network.

What You Pay for Care

Below is a summary of how certain services are covered. For a more complete list and any limitations, visit HRConnect to view the summary plan description (SPD).

To see employee premium contributions for the medical plan, visit the enrollment site.

Your Annual Deductible and Out-of-Pocket Maximum

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Annual Deductible
Individual: $0
Family: $0
Individual: $1,750
Family: $3,500
Individual: $10,000
Family: $20,000
Out-of-Pocket Maximum [1]
Individual: $3,000
Family: $6,000
Individual: $8,150
Family: $16,300
Individual: $30,000
Family: $60,000

[1] Amounts paid toward care provided by all in-network providers accumulate toward both the YNHHS and Anthem PPO out-of-pocket maximums. However, when the YNHHS in-network out-of-pocket maximum has been reached, amounts paid for YNHHS in-network care no longer accrue toward the Anthem PPO out-of-pocket maximum. Amounts paid for Anthem PPO in-network care continue to accrue until the Anthem PPO out-of-pocket maximum is met.

Office Visits and Physician Services

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Primary Care Visit (in-person or electronic) [1,2]
$10 copay
$30 copay
50% of MAA* after deductible
Specialist Office Visit (in-person or electronic) [1]
$25 copay
$50 copay
50% of MAA* after deductible
Routine Adult Exam [1,3]
0%, no copay
0%, no copay
50% of MAA* after deductible
Doctor or Surgeon Services [4]
0%, $0 copay
20% after deductible
50% of MAA* after deductible
Allergy Shot in Doctor's Office (no MD visit)
$10 copay
$30 copay
50% of MAA* after deductible
Nutrition Counseling and Diabetes Self-Management Training
0%, no copay
0%, $0 copay
50% of MAA* after deductible

* Maximum allowable amount

[1] Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the ACA. Check with your provider or call Anthem to determine if a specific test is covered at 100%. In addition, some Tier 1 providers send lab work to a Tier 2 lab. In this case, the lab work is covered as a Tier 2 benefit.

[2]Find a list of Signature providers.

[3] One exam every calendar year starting at age 22 (includes immunizations).

[4] Other than office visit; includes maternity claims.

Women and Children

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Well-Woman Visit (OB/GYN preventive exam) [1]
0%, $0 copay
0%, $0 copay
50% of MAA* after deductible
Mammography [2] (including 3D and bone density test)
0%, $0 copay
0%, $0 copay
50% of MAA* after deductible
Screening Breast Ultrasound (if dense breast tissue or a history)
$20 copay
$20 copay
50% of MAA* after deductible
Maternity Care [3] (initial visit)
$10 copay
$30 copay
50% of MAA* after deductible
Well-Baby/Well-Child Care [4,5]
0%, $0 copay
0%, $0 copay
50% of MAA* after deductible
Specialized Infant Formula
N/A
50% coinsurance
50% of MAA* after deductible
Infertility Services [6]
100% up to lifetime max with limits for certain services [6]
50% up to lifetime max with limits for certain services [6]
N/A

* Maximum allowable amount

[1] One per calendar year. All other OB/GYN office visits are covered at the specialist office visit benefit level.

[2] Screening mammography only. Does not include breast ultrasounds.

[3] Prenatal care and delivery. Well visits to the obstetric provider are billed with one global fee that includes trimester visits, delivery, and postpartum care. Any maternity-related tests that are needed, such as blood work, glucose tolerance tests, stress tests, ultrasounds, or amniocentesis, are billed separately. Inpatient hospital and doctor or surgeon services also apply.

[4] Seven exams from birth to age 1 year; seven exams from ages 1 to 5; one exam from ages 6 to 21.

[5]Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the ACA. Check with your provider or call Anthem to determine if a specific test is covered at 100%.

[6]The plan covers in-network fertility services only through YNHHS and Anthem PPO providers. YNHHS providers: Yale Reproductive Endocrinology and Infertility (REI) Center and YNHHS Apothecary. 100% up to lifetime max of $14,000 for medical and freezing and transferring embryos, and 100% up to lifetime maximum of $2,000 for prescription drugs through the pharmacy benefit. Anthem PPO providers: 50% of covered medical services at a participating Anthem provider, plus covered prescription drugs at a participating CVS Caremark pharmacy, up to a combined lifetime maximum of $10,000.

Ancillary Services

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Lab Services
$25 copay
20% after deductible
50% of MAA* after deductible
Diagnostic Testing [1] (facility charges only)
$25 copay
20% after deductible
50% of MAA* after deductible
High-Tech Diagnostic Imaging [2] (facility charges only)
$100 copay
20% after deductible
50% of MAA* after deductible
Colorectal Cancer Screening [3]
0%, $0 copay
0%, $0 copay
50% of MAA* after deductible
Chiropractic Visits [4]
N/A
$30 copay
50% of MAA* after deductible
Physical and Occupational Therapy [4]
$10 copay
$10 copay
50% of MAA* after deductible
Speech Therapy [4]
$10 copay
$10 copay
50% of MAA* after deductible
Cardiac Rehabilitation [5]
$10 copay
$30 copay
50% of MAA* after deductible

* Maximum allowable amount

[1] Includes x-rays, echo stress tests, ultrasounds, diagnostic mammograms, sleep studies, and EKGs. Patients will receive a bill for the reading of the diagnostic testing and imaging (covered under “Doctor or Surgeon Services”).

[2] PET, SPECT, MRI, MRA, CTA, and CAT.

[3] Diagnostic colonoscopies covered under the outpatient surgery benefit level. Includes fecal occult blood test, barium enema, flexible sigmoidoscopy, and screening colonoscopy.

[4] Chiropractic, physical therapy, occupational therapy, and speech therapy combined maximum: 50 visits per calendar year.

[5] Cardiac rehabilitation: maximum 36 visits per calendar year.

Inpatient and Outpatient Care

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Inpatient Hospital Services [1]
$250 copay
20% after deductible
50% of MAA* after deductible
Outpatient Surgery [2]
$100 copay
20% after deductible
50% of MAA* after deductible
Infusion and Radiation Therapy (including medications) [3]
$25 copay
20% after deductible
50% of MAA* after deductible
Pathologists, Radiologists, and Anesthesiologists [3]
0%, $0 copay
0%, $0 copay
50% of MAA* after deductible

* Maximum allowable amount

[1] Room and board, lab work, medical supplies, and other hospital ancillary services.

[2] Hospital or surgical center facility charges only.

[3] Some Tier 1 providers send lab work to a Tier 2 lab. In this case, the lab work is covered as a Tier 2 benefit.

Behavioral Health and Substance Abuse

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Inpatient Treatment (facility charges only)
$250 copay
20% after deductible
50% of MAA* after deductible
Outpatient Treatment [1]
$10 copay
$10 copay
50% of MAA* after deductible
ABA Therapy [2]
N/A
$10 copay
50% of MAA* after deductible

* Maximum allowable amount

[1] The Employee and Family Resources (EFR) program provides up to six (6) confidential counseling sessions at no cost.

[2] Applied behavioral analysis, up to age 21.

Urgent and Emergency Care and Telehealth

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Emergency Department
$250 copay
$250 copay
$250 copay
Urgent Care Facility and Walk-In Medical Center
$25 copay
$50 copay
$50 copay
Ambulance
N/A
0%
0%
Telehealth (OnDemand and LiveHealth Online only)
0%, $0 copay
$30 copay
Not covered
Observation (non-emergency related)
$100 copay
20% after deductible
50% of MAA* after deductible

Non-Acute Care

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Skilled Nursing Facility [1]
20% coinsurance
20% coinsurance, no deductible
50% of MAA* after deductible
Home Health Care [2]
20% coinsurance
20% coinsurance, no deductible
50% of MAA* after deductible
Hospice Care [3]
N/A
20% coinsurance, no deductible
50% of MAA* after deductible

* Maximum allowable amount

[1] Up to 120 days per calendar year after a hospital stay.

[2]Up to 120 days per calendar year.

[3]Up to 60 days per calendar year.

Other

Signature Facility/Provider
Anthem PPO Provider
Out-of-Network Provider
Durable Medical Equipment
N/A
20% coinsurance, no deductible
50% of MAA* after deductible
Hearing Aids [1]
N/A
50% coinsurance, no deductible
50% of MAA* after deductible
Orthotics
N/A
50% coinsurance, no deductible
50% of MAA* after deductible

* Maximum allowable amount

[1]Two hearing aids every 36 months.

Save With Signature Providers & Facilities

The following examples* show how using a Signature provider and facility can save you money. As a reminder, if you use a Signature provider but your care takes place in a facility that is not in our network, the facility expenses will be covered as Anthem or out-of-network care.

Example #1: Signature Savings
Tony saves $5,750 using a Signature provider and Signature facility for his knee surgery.

Facility Charge Allowed
Doctor or Surgeon Fees Allowed
Annual deductible (paid by Tony)
Amount Left to Pay
Tony’s Cost after Deductible (including inpatient copay/coinsurance)
Total Amount Plan Pays
Total Amount Tony Pays
YNHHS Signature Provider & Facility
$20,000
$3,000
$0
$23,000
$250
$22,750
$250
Anthem PPO Provider & Facility
$20,000
$3,000
$1,750
$21,250
20% = $4,250
$17,000
$4,250 + $1,750 = $6,000
Example #2: Signature Provider + Anthem Facility Costs
If Tony had the same procedure but it takes place in an Anthem facility, he will spend $5,150 more than in the first example.

Facility Charge Allowed
Doctor or Surgeon Fees Allowed
Annual deductible (paid by Tony)
Amount Left to Pay
Tony’s Cost after Deductible (including inpatient copay/coinsurance)
Total Amount Plan Pays
Total Amount Tony Pays
YNHHS Signature Provider
N/A
$3,000
$0
$3,000
$0 owed for doctor or surgeon fees
$3,000
No charges for the YNHHS Signature Provider
Anthem Facility
$20,000
N/A
$1,750 (for Anthem facility)
$18,250
20% for facility = $3,650 ($18,250 x 20% = $3,650)
$14,600
$5,400 for the Anthem Facility ($1,750 deductible + $3,650 coinsurance)
Example #3: Anthem Provider + Anthem Facility Costs
If Tony uses an Anthem provider and an Anthem facility, he will spend $600 more than in the second example.

Facility Charge Allowed
Doctor or Surgeon Fees Allowed
Annual deductible (paid by Tony)
Amount Left to Pay
Tony’s Cost after Deductible (including inpatient copay/coinsurance)
Total Amount Plan Pays
Total Amount Tony Pays
Anthem PPO Provider & Facility
$20,000
$3,000
$1,750
$21,250
20% = $4,250 ($21,250 x 20%)
$17,000
$4,250 + $1,750 = $6,000

* These examples are for illustrative purposes only. Your actual cost share may vary depending on the care you receive, the facility used, and specifics if you’re admitted as an inpatient. These examples are not provided as a guarantee of coverage or an actual estimate of specific benefits under the plan.

When to Connect with Anthem

For a medical stay and/or service preauthorization, call 800-238-2227 (in Connecticut) or 800-248-2227 (out of state). For behavioral health or substance abuse stays, call 800-934-0331.

Before receiving any of these services, you must call Anthem for preauthorization. Otherwise, your benefits will be reduced.

  • Inpatient stays in a hospital, skilled nursing facility, hospice facility, subacute care or acute rehabilitation facility, or behavioral health or substance abuse treatment center (call at least 24 hours before the start of your stay)
  • High-cost diagnostic imaging services prescribed by an out-of-network provider
  • Organ/tissue transplants, including evaluation, donor search, organ procurement/tissue harvest, or transplant

For admissions following emergency or urgent care, you, your representative, or your doctor must call Anthem within 48 hours of admission.

If you do not precertify for the services above:

  • Benefits for inpatient stays will be reduced by $200.
  • Benefits for doctor fees will be reduced by 25%.

You can also connect with Anthem to:

  • Find a provider in the Anthem Century Preferred Network
  • Resolve insurance claim and billing issues
  • Ask questions about preventive and/or diagnostic care
  • Get general health information

Connect with…

HRConnect
Monday–Friday,
7:30 a.m. to 5 p.m. ET
844-543-2147
203-200-3838 (fax)
Website
Choose the YNHH_PRD option

Anthem Blue Cross and Blue Shield
844-963-0447
Website

Patient Resource Coordinators (PRC) for the YNHHS Medical Plan
844-543-2147, press option 3

COBRA
bswift
866-365-2413

Health Savings Account (HSA)
HSA Bank
866-357-6246
Website

Telehealth
LiveHealth Online
888-548-3432
Website

OnDemand
833-483-5363
Website

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