PPO Plan

PPO Plan  


The PPO Plan offers lower out-of-pocket costs in exchange for higher premiums. With this plan, your costs are more predictable, but you’ll likely still have out-of-pocket expenses. Instead of an HSA, this plan allows you to contribute pre-tax money to a Health Care Flexible Spending Account (FSA).


How the PPO Plan works

  • You receive in-network preventive care at no cost. This includes annual physicals, immunizations, and recommended screenings.
  • For nonpreventive doctor’s visits and generic prescriptions, you pay a flat copay without needing to meet the deductible.
  • For most other health care services, you pay 100% of the negotiated costs until you meet the annual deductible.
  • Once you satisfy the deductible, you’ll pay a percentage of your covered medical expenses; this amount is called your coinsurance.
  • If your deductible and coinsurance expenses reach the out-of-pocket maximum, then the plan pays 100% of your eligible expenses for the rest of the year.


Use your PPO Plan wisely

Here are ways to make the most of your plan all year long.


  • Track your stats. Log in to the Anthem website to see how much of your deductible you’ve met, review claims, and more.
  • Pair it with a Health Care FSA. If you enroll in the Health Care FSA, you can set aside pre-tax dollars to help pay for your out-of-pocket costs. Keep in mind, the money in your FSA does not carry over to the next plan year; you must “use it or lose it.”
  • Be cost-conscious. Visit the Anthem website to search for in-network providers and use the tools to compare costs for medical services.
Contact Us


  • What if I have payroll deduction questions?

    Call Mercer Voluntary Benefits at 1-800-557-0743.
  • What is long term care?

    It is the kind of care you may need when you are no longer able to take care of yourself. Long term care provides supportive services for an extended period of time in the place best suited to your needs. That’s different from acute care, which is medical care provided for a short period of time to treat a certain condition or illness.

    You can receive long term care in a nursing home, in your own home, or in an adult day care center and other types of care facilities may be covered. The mix and levels of care vary with different policies. Long term care includes services such as:

    • skilled, intermediate, and custodial nursing home care,
    • therapy ordered by a physician and provided by a registered nurse or other qualified health care professional,
    • assistance with the activities of daily living, such as bathing, eating, or dressing, provided by formal or informal caregivers.
  • When might I need long term care?

    You might need long term care at any age, for a variety of reasons. Long term care may become necessary when you need help or supervision from another person in performing activities of daily living, such as bathing, eating, or dressing that requires supervision for the protection of yourself or others. You may require such care because of an accident or illness. Or you may need long term care services due to the effects of aging.
  • How much does long term care cost?

    Long term care costs can be very high. The current average annual cost of nursing home care is $67,5251, but costs can be higher depending on where you live. Care in an assisted living facility or at home can be expensive too: Average annual cost today for care in an assisted living facility is $38,220 and for in-home care is $43,472.1

    And, like everything else, long term care expenses are expected to rise.

    To learn more simply call 1-800-557-0743.


    1Genworth 2010 Cost of Care Survey, April 2010
    2 Ibid.
    3 Harris, Rothenberg International: Study of average costs of nursing homes and assisted living facilities in the United States, by city and State. July 2002.
    * In California, Medicaid is known as Medi-Cal. Medicaid eligibility is complex and varies by state. Contact your local Medicaid Office for complete information.
    ** California refers to this as a Residential Care Facility.

  • What is the cost of waiting to purchase long term care insurance?

    If you are thinking of waiting to purchase long term care insurance coverage, consider the impact of waiting:

    • Increases the risk of being ineligible for insurance
    • Decreases the overall time you have long term care insurance coverage
    • Can increase the overall cost of coverage because premium rates increase with age

    Waiting delays covering your long term care risk and can cost you money.

  • Won't my other health care plans cover these types of expenses?

    No. While health care plans cover a wide range of services, they are designed to pay for acute care costs, not long term care expenses. Although most health benefits may pay for doctor’s visits or hospitalizations, they will probably not pay for home health aides or extended nursing home stays.
  • Won't the federal government cover these types of expenses?

    While many people think the federal government pays for long term care expenses, nationally, over 25 percent of all nursing home expenses are paid out-of-pocket by individuals and their families. Neither Medicare, Medicare Supplement Insurance nor the major medical health insurance provided by employers is designed to pay for long term care expenses.
  • But doesn't Medicare cover long term care?

    Medicare provides limited coverage for skilled nursing care following a hospitalization or extended nursing home stay, but only if the care is provided in a Medicare-approved facility. (Such approved facilities comprise less than half of all nursing homes in the country.) However, many conditions requiring long term care services, do not require hospitalization; Alzheimer's disease is a good example.
  • Do Medicare supplement plans cover long term care?

    No. Medicare supplement plans (also called Medigap policies) are designed to pay some or all of Medicare’s deductible and co-payments. These policies follow the same coverage guidelines as Medicare and generally cover only Medicare-approved services, not long term care.
  • To what extent does Medicaid cover long term care?

    Medicaid* — a joint federal and state assistance program — pays for a large share of the nation’s nursing home expenses. However, the purpose of Medicaid is to provide assistance to persons with very low incomes, few assets, and high medical bills. To qualify for Medicaid benefits, you must meet stringent financial conditions and “spend down” your personal assets. (Qualification requirements vary by state.) Income limits may apply.

    *In California, Medicaid is known as Medi-Cal. Medicaid eligibility is complex and varies by state. Contact your local Medicaid Office for complete information.

  • How to file a claim?

    The insured or his or her designee begins the process by calling 1-800-557-0743.