HSA Plan Benefits
$2,700 Individual Deductible
$5,400 Family Deductible

Plan Name	Assurant HSA
PCY = per calendar year	Participating Provider	Non-Participating Provider
Lifetime Maximum	$3 million per individual ($6 million available for an additional cost)
Annual Deductible Per calendar year the deductible applies to all expenses unless otherwise noted	Individual Plan: $2,700 Family Plan: $5,400	Individual Plan: $3,700 Family Plan: $7,400
Coinsurance Benefit paid by Assurant Health unless otherwise noted	80%	60%
Annual Coinsurance Maximum Per calendar year	Individual Plan: $2,000 Family Plan: $4,000	Individual Plan: $8,000 Family Plan: $16,000
Annual Out-of-Pocket Maximum Per calendar year; includes annual deductible and coinsurance maximum; once the out-of-pocket maximum is met, providers are covered in full	Individual Plan: $4,700 Family Plan: $9,400	Individual Plan: $11,700 Family Plan: $23,400
Preventive Exam & Screening Includes routine exam, well child care, Pap smear, prostate cancer screening, colorectal cancer screening, cholesterol screening, urinalysis
	First $500 per calendar year no deductible & paid at 100% After first $500 paid at 80% after annual deductible	60%
Mammography No deductible	80%	60%
Immunization	Covered under Preventive Exam & Screening shown above
Plan Name	Assurant HSA
PCY = per calendar year	Participating Provider	Non-Participating Provider
Office Visit	80%	60%
Naturopathy	80%	60%
Spinal (Chiropractic) Manipulation 10 visits limit per calendar year	80%	60%
Acupuncture 10 visits limit per calendar year	80%	60%
Mental Health Outpatient Office Visit	80%	60%
Outpatient Diagnostic Imaging (X-Ray) and Lab Services	80%	60%
Other Outpatient & Inpatient Professional Services	80%	60%
Inpatient & Outpatient Facility Care	80%	60%
Maternity (Complications)	80%	60%
Maternity (Routine)	Not covered
Mental Health Inpatient Facility Care	80%	60%
Pharmacy - Retail	Not covered
Pharmacy - Mail Service	Not covered
Plan Name	Assurant HSA
PCY = per calendar year	Participating Provider	Non-Participating Provider
Vision - Routine Exam	Not covered (Dental-Vision Discount Plan available for an additional $9.95 per month per family)
Vision Hardware Frames, lenses and contact lenses	Not covered (Dental-Vision Discount Plan available for an additional $9.95 per month per family)
Emergency Room Care $75 copay per emergency room visit; copay waived if admitted	80%
Ambulance Transportation	80%	60%
Skilled Nursing Facility 45 days limit per calendar year	80%	60%
Durable Medical Equipment and Prosthetics $500 lifetime maximum benefit	80%	60%
Home Health Care 130 visits limit per calendar year	80%	60%
Hospice Care Inpatient: 10 days PCY Respite: 240 hours limit PCY	80%	60%
Rehabilitation Includes physical, occupational, massage and speech therapy; cardiac & pulmonary rehabilitation Inpatient: 10 days limit PCY Outpatient: 20 visits limit PCY	80%	60%
Transplants (Kidney, Cornea and Skin) 12-month waiting period	80%	60%
Transplants (Bone Marrow, Heart, Liver and Lung) 12-month waiting period $250,000 lifetime maximum $500,000 lifetime maximum when performed by a designated transplant provider Up to an additional $10,000 benefit toward travel expenses when using a designated transplant provider	80%	Not covered
Occupational Injury or Disease	Covered as for any other condition (limited to partners, proprietors or corporate officers who are not covered by a Workers' Compensation Act or other similar law)
Pre-Existing Conditions	A pre-existing condition is a sickness, pregnancy or injury, and related complications for which, during the six-month period immediately prior to the effective date of your health insurance coverage: a) You sought, received or were recommended medical advice, consultation, diagnosis, care, or treatment. b) Prescription drugs were prescribed. c) Symptoms were produced, or diagnosis was possible.   No benefits are paid for charges incurred due to a pre-existing condition until you have been continuously insured under the plan for nine months. After the nine-month period, benefits are paid for a pre-existing condition. In some cases, Assurant Health will apply credit for pre-existing conditions if the person enrolling has been covered by a prior group or individual health benefit plan that is considered "creditable" coverage at any time during the 63 (sixty-three) day period immediately preceding the receipt date of the application.
Benefit Waiting Period for Certain Treatment	In addition to the transplant and pre-existing condition waiting periods shown above, benefits for certain types of treatment are payable after a 6-month waiting period for the services shown below: Durable and personal medical equipment ($500 lifetime maximum) Face and jaw dysfunction services ($600 lifetime maximum) Surgical treatment of bunions, hemorrhoids, inguinal hernia, varicose veins Surgical treatment of tonsils/adenoids

Medically Necessary Care: Treatment must be medically necessary to be covered. Medically necessary services or supplies must be:

• Appropriate and consistent with the diagnosis.

• Commonly accepted as proper treatment.

• Reasonably expected to result in improvement of the condition.

• Provided in the least intensive setting without affecting the quality of medical care provided.

Maximum Allowable Amount: The maximum allowable amount is the most the plan pays for covered services. If you use an out-of-network provider, you are responsible for any balance in excess of the maximum allowable amount.

Network Services: When you use network providers, covered charges are eligible for discounts and never exceed the maximum allowable amount.

Out-of-Network Services:

• Emergencies: Covered services are always paid at the network benefit percentage - even if you are out of network - subject to the maximum allowable amount.

• Non-emergencies: Covered services are subject to the out-of-network deductible, the maximum allowable amount provision, the out-of-network coinsurance, and the increased out-of-network coinsurance out-of-pocket maximum.

Utilization Review: Authorization is required before receiving inpatient treatment and certain types of outpatient procedures. Unauthorized services will result in a penalty. Unauthorized transplants are not covered.