Employee Health Insurance Information

The amount deducted from your paycheck every pay period to maintain your health insurance coverage. This is often called a “premium buy-up” when you choose a plan above the employer-paid Bronze option.

Our Plans:

• Bronze: $0 per check (fully employer-paid)
• Silver: $45.04 per check ($1,170/year buy-up)
• Gold: $117.24 per check ($3,048/year buy-up)

Critical Distinction: Premium buy-up does NOT count toward your out-of-pocket maximum. You pay the premium whether you use insurance or not, and you pay separate costs when you use covered services (deductible, coinsurance, copays).

The amount you must pay out-of-pocket before insurance starts covering most services. This resets every January 1.

Our Plans:

• Bronze: $4,000 deductible
• Silver: $3,000 deductible
• Gold: $3,000 deductible

Exception: Preventive care (annual physicals, mammograms, immunizations) is always free, even before meeting your deductible.

Example: If you have surgery in March that costs $8,000 and you haven’t used your insurance yet, you pay the first $3,000 or $4,000 (depending on plan), then insurance covers the rest according to coinsurance.

After you meet your deductible, you and the insurance company share the cost of services. This is expressed as a percentage.

Our Plans:

• Bronze: You pay 30%, insurance pays 70%
• Silver: You pay 20%, insurance pays 80%
• Gold: You pay 20%, insurance pays 80%

Example: After meeting your deductible, you need a $1,000 test. With Silver/Gold, you pay $200 (20%), insurance pays $800 (80%).

The maximum amount you’ll pay for covered services in a calendar year. Once you hit this limit, insurance pays 100% of covered services for the rest of the year.

Our Plans:

• Bronze: $9,500 out-of-pocket max
• Silver: $7,000 out-of-pocket max
• Gold: $7,000 out-of-pocket max

What COUNTS toward OOP Max: Deductible, coinsurance, and copays for covered services.

What DOES NOT count: Premium buy-up (payroll deductions), out-of-network care (for HPN plans), or non-covered services.

Why this matters: In a catastrophic year (serious illness, major surgery), you’ll never pay more than the out-of-pocket max for covered services. This is your financial protection. You still pay your premium buy-up separately.

A flat dollar amount you pay for certain services, like doctor visits or prescriptions. Copays are usually not subject to the deductible.

Common Copays in Our Plans:

• Primary care visit: Typically $25-$35
• Specialist visit: Typically $50-$75
• Urgent care: Typically $75-$100
• ER visit: Typically $250-$500
• Generic prescription: Typically $10-$20

Note: Exact copays vary by service. Check your Summary of Benefits and Coverage (SBC) for details.

In-Network: Doctors and hospitals that have contracted with Blue Cross to provide services at negotiated (lower) rates. Your plan covers in-network care at the percentages listed above.

Out-of-Network: Providers who have NOT contracted with Blue Cross. You’ll pay significantly more, or services may not be covered at all.

Critical for Yates Plans:

• Bronze and Silver (HPN): ONLY Duke Health providers are in-network. UNC, WakeMed, and Rex are out-of-network and won’t be covered except for emergencies.
• Gold (PPO): All NC providers are in-network, including Duke, UNC, WakeMed, and Rex. Out-of-network coverage available at 50%.

Bottom Line: Always verify your provider is in-network before scheduling non-emergency care. Use the Blue Cross provider search.

HPN (Health Provider Network): A limited network built around Duke Health. Lower premiums, but you MUST use Duke providers for most care.

PPO (Preferred Provider Organization): A broader network that includes ALL North Carolina providers. Higher premiums, but maximum flexibility.

Which plans use which network?

• Bronze (HPN-45): HPN only
• Silver (HPN-35): HPN only
• Gold (Blue Options-35): PPO

Key Decision Point: If your doctors are at UNC, WakeMed, or Rex, you MUST choose Gold. Bronze and Silver will NOT cover care at these facilities except for emergencies.

Services designed to prevent illness or detect health issues early. Federal law requires all plans to cover preventive care at 100%, with no deductible or copay.

Examples of Free Preventive Care:

• Annual physical exam
• Well-child visits
• Immunizations (flu shot, COVID vaccine, etc.)
• Mammograms (age 40+)
• Colonoscopy (age 45+)
• Blood pressure screening
• Cholesterol screening
• Depression screening
• Diabetes screening
• Birth control counseling

Important: If your doctor finds something during a preventive visit and orders additional tests or treatment, THOSE services may be subject to your deductible and coinsurance.