Rocky Mountain Healthcare

Employer Application
Package
Employee Application Package
for New Group
Add Employee to Existing
Group Plan
Employee Waiver
Business Group of One
Complete Application
Employee Change Form
Employee Disenrollment
Form
Continuation of Coverage
Common Law Form   Overage Dependent
Form
Student Status Form   EFT Premium Payment
Form
Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.
Plan Descriptions

HMO Plans

Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Basic HMO
$30

$400/day, max $1600

$150

Basic HMO w/ MPHH

$30 $400/day, max $1600 $150
Standard HMO $20 $150/day, max $600

$50

C15K $25 50% to $15K 50% to $15K
C1000 $15 50% to $1K, 20% next $4K same as hospital
C5000 $20 50% to $5K 50% to $5K
C-1 $15 50% to $1K, 25% next $6K same as hospital
C-3 $15 50% to $3K, 20% next $7500 same as hospital
C-8 $20 50% to $8K 50% to $8K
NC50 $15 50% to $500, 20% next $2500 same as hospital
Choice 500-90 $15 $500 + 10% to $30K same as hospital
Choice 1000-90 $15 $1000 + 10% to $30K same as hospital
Choice 1500-80 $20 $1500 + 20% to $30K same as hospital
Choice 3000-80 $20 $3000 + 20% to $30K same as hospital

Direct D-100

$15 $100 + $300/day, $1300 max $300
Direct D-300 $15 $300 + $300/day, $1500 max $500
Direct E-200 $20 $200 + $500/day, $2200 max $450
Direct E-400 $20 $400 + $500/day, $2400 max $650
Direct E-1200 $20 $1200 + $500/day, $3200 max $1450
Direct E-3000 $20 $3000 + 20% to $30K same as hospital
Direct F-300 $25 $300 + $750/day, $3300 max $650
Direct F-600 $25 $600 + $750/day, $3600 max $950
Direct F-1200 $25 $1200 + $750/day, $4200 max $1550
Direct G-1800 $30 $1800 + $750/day, $4800 max $2200
Plan A $15 $300/day, $1200 max $200
Plan B $20 $500/day, $2000 max $250

Plan C

$25 $750/day, $3000 max $350

PPO Plans

Plan Name
Office Visit Copay
Deductible
Coinsurance
$30
$3000

30% to $5,000 max

Basic PPO
w/ MPHH
$30
$3000
30% to $5,000 max
$30
$1000
20% to $2,000 max
$30
$1000
20% to $2,000 max
$15
$500
20% to $15K
$15
$500
10% to $30K
$15
$1000
20% to $15K
$15
$1000
10% to $30K
$20
$1500
20% to $30K
$20
$3000
20% to $30K
$25
$5000
20% to $50K
$25
$10,000
$20% to $50K
  Office Visit Copay Hospital Copay
Outpatient Copay
$15
$300/day, $1200 max
$200
$15
$300/day, $1200 max
$200
$20
$500/day, $2000 max
$250
$20
$500/day, $2000 max
$250
$25
$750/day, $3000 max
$350
$25
$750/day, $3000 max
$350
$15
$100 + $300/day, $1300 max
$300
$15
$300 + $300/day, $1500 max
$500
$20
$200 + $500/day, $2200 max
$450
$20
$400 + $500/day, $2400 max
$650
$20
$1200 + $500/day, $3200 max
$1450
$20
$3000 + $500/day, $5000 max
$3250
$25
$300 + $750/day, $3300 max
$650
$25
$600 + $750/day, $3600 max
$950
$25
$1200 + $750/day, $4200 max
$1550
$30
$1800 + $750/day, $4800 max
$2200

 

HSA Plans

Plan Name
Deductible
Coinsurance
Max Out-of-Pocket
$1000/$2000
80/20
$4000/$8000
$2500/$5000
80/20
$5000/$10,000
$5000/$10,000
100/0
$5000/$10,000
$1000/$2000
80/20
$4000/$8000
$2500/$5000
80/20
$5000/$10,000
$5000/$10,000
100/0
$5000/$10,000
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