| |
Employee Medical Benefit Plan Summary
HSA Plan 1500
Effective July 1, 2008
| Annual Deductible |
In Network |
Out of Network |
| Single |
$1,500 |
$2,250 |
| Family |
$3,000 |
$4,500 |
| |
|
|
Annual Out-of-Pocket Maximum
(includes deductable) |
In Network |
Out of Network |
| Single |
$3,000 |
$4,500 |
| Family |
$6,000 |
$9,000 |
| |
|
|
| |
| Lifetime Maximum Benefit - $2,000,000 per person |
| |
| Description of Benefits |
Benefit Amount with a
Preferred Provider |
Benefit Amount with an
Out of Network Provider |
Special Conditions |
| Amounts are a % of the allowed charge after in-network deductible has been met |
Amounts are a % of the allowed charge after out-of-network deductible has been met |
Before
out-of-pocket maximum is met |
After
out-of-pocket maximum is met |
Before
out-of-pocket maximum is met |
After
out-of-pocket maximum is met |
| |
| Hospital Services |
| Inpatient |
90% |
100% |
70% |
100% |
Preauthorization may be required. |
| Outpatient |
90% |
100% |
70% |
100% |
| Professional Health Care Provider Services |
Inpatient,
Outpatient and
Surgical
Services |
90% |
100% |
70% |
100% |
|
| Home and Office Visits |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Wellness Services |
All wellness services:
Deductible does not apply in-network up to benefit maximum
Maximum benefit of $2000 per calendar year per person
After benefit maximum is met, deductible and coinsurance applies |
Routine Physical
Exams |
100% |
100% |
No Coverage |
No Coverage |
| Well Child Care to age 6, including immunizations |
100% |
100% |
No Coverage |
No Coverage |
| Cancer Screenings |
100% |
100% |
No Coverage |
No Coverage |
| Diagnostic Services |
| Lab, X-ray, MRI |
90% |
100% |
70% |
100% |
|
| Colonoscopy |
90% |
100% |
70% |
100% |
Deductible does not apply. |
| Mental Health/Chemical Dependency Services |
Preauthorization may be required. |
| Inpatient |
90% |
100% |
70% |
100% |
10 visits maximum per calendar year; 30 visits maximum per lifetime. |
| Outpatient |
90% |
100% |
70% |
100% |
40 hours maximum per calendar year. |
| Emergency Services |
Ambulance
Services |
90% |
100% |
70% |
100% |
|
Emergency
Room Charge |
90% |
100% |
70% |
100% |
|
| Urgent Care Services |
Professional
Health Care
Provider Visit |
90% |
100% |
70% |
100% |
|
Emergency
Room Charge |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Chiropractic Services |
Home and Office
Visits |
90% |
100% |
70% |
100% |
12 visits per Calendar Year Max, additional visits require authorization. |
| All Other Eligible Expenses |
90% |
100% |
70% |
100% |
|
|
|
Plan 250
