Click
here to
link to our site
Rocky Mountain Healthplans
|
Click on the button below to obtain the appropriate forms. These are pdf files to be printed, completed, and faxed to our office.
| Employee Application Package for New Group | Add Employee to Existing Group Plan | Employee Waiver |
Other Forms:
Business Group of One - Complete Application
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.
HMO Plans
| Health Plan Name |
Office Visit Copay |
Hospital Copay |
Outpatient Copay |
| Basic HMO | $30 |
$400/day, max $1600 |
$150 |
| $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 |
| $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 |
| $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 |
 |
Click
below for: Roper Individual Health Insurance Services |
 South Metro Denver Chamber of Commerce |
 |
