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HSA Healthplan
Comprehensive & HSA Healthplan Benefits
$1,500, $2,500 or $3,500 Deductible for Individuals
$3,000, $5,000 or $7,000 Deductible for Families (2 or more family members)
This is
a Preferred Provider (PPO) plan that does not require a
referral to see another doctor. As long as you are treated by a PPO
provider when you receive medical care, you'll receive the higher
Preferred Plan benefit (80%).
HSA Healthplan Comprehensive includes benefits for prescription
drug and maternity expenses. The HSA Healthplan does not cover these
expenses. Both plans offer preventive care benefits. Neither plan
covers vision care expenses.
Chances are excellent that your doctor is an Asuris Northwest Health PPO
plan provider. Click
here to see if your doctor or practitioner belongs to the "Preferred" network
(in the "Plan:" drop-down box choose "Asuris
Preferred").
The percentages shown below are the amounts paid by Asuris Northwest
Health.
To download
and/or print a summary
of HSA Healthplan benefits,
click on one of the
following plan names:
HSA Healthplan Comprehensive or
HSA
Healthplan. |
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|
Plan Name |
HSA Healthplan
Comprehensive |
HSA Healthplan |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized Provider |
Annual Deductible PCY
HSA Healthplan
Comprehensive offers only one deductible choice for individual or
family coverage; choose one of the
2 HSA Healthplan deductible options shown for individual or family coverage
the deductible applies to all expenses unless otherwise specified |
Individual
Coverage
$1,500
Family Coverage
$3,000
|
Individual
Coverage
$2,500 or $3,500
Family Coverage
$5,000 or $7,000
|
|
Lifetime Maximum |
$2 million per individual |
Annual Coinsurance Maximum
Per
calendar year |
Individual
$3,500
Family
$7,000
|
Unlimited |
Individual
$2,500 or $1,500
Family
$5,000 or $3,000
|
Unlimited |
Out-of-Pocket Maximum
PCY;
includes annual deductible and coinsurance maximum; once the
out-of-pocket maximum is met, Preferred Providers are covered in full |
Individual
$5,000
Family
$10,000
|
Unlimited |
Individual
$5,000
Family
$10,000
|
Unlimited |
Preventive Care
No deductible |
80% |
60% |
80% |
60% |
|
Immunizations |
Included in Preventive Care shown above |
|
Office, Home & Outpatient Hospital Visits |
80% |
60% |
80% |
60% |
|
Other Outpatient Professional Services & Inpatient Professional Care |
80% |
60% |
80% |
60% |
Prescription Drugs
$2,000 maximum benefit
per person PCY |
50% after
annual deductible
is met |
Not covered |
|
Routine Vision Exam |
Not covered |
Vision Hardware
Frames,
lenses and contact lenses |
Not covered |
|
Outpatient Diagnostic Imaging (X-Ray) & Lab Services |
80% |
60% |
80% |
60% |
Mammography
No deductible
for routine
mammograms only |
80% |
60% |
80% |
60% |
|
 |
|
Plan Name |
HSA Healthplan
Comprehensive |
HSA Healthplan |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized Provider |
|
Cholesterol Screening |
Included in
Preventive Care shown above |
Prostate Cancer Screening
No deductible
for routine screening |
80% |
60% |
80% |
60% |
|
Facility Care (Hospital) Inpatient & Outpatient |
80% |
60% |
80% |
60% |
Skilled Nursing Facility
30 days limit PCY |
80%* |
Emergency Room Care
see the
Emergency Care paragraph
shown toward the bottom of this page) |
80% |
60% |
80% |
60% |
Ambulance Services
$2,000
maximum benefit PCY
for ground services |
80%** |
|
Maternity Care |
80% |
60% |
Not covered |
Spinal and Other Manipulations
10 visits limit
PCY |
80% |
60% |
80% |
60% |
Acupuncture Services
12 visits limit PCY |
80% |
60% |
80% |
60% |
|
Naturopathic Services |
80% |
60% |
80% |
60% |
Home Medical Equipment
$2,500 maximum benefit PCY |
80% |
60% |
80% |
60% |
|
Prostheses and Orthotics |
80% |
60% |
80% |
60% |
|
Special Equipment and Supplies |
80% |
|
|
|
Plan Name |
HSA Healthplan
Comprehensive |
HSA Healthplan |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized Provider |
Home Health Care
130 visits limit PCY |
80% |
Hospice Care
6-month benefit maximum |
80% |
Mental Disorders
Inpatient - 8 days limit PCY
Outpatient - 12 visits limit PCY |
80% |
60% |
80% |
60% |
Rehabilitation
Including physical,
occupational, speech and massage therapy
Maximum benefit PCY:
Inpatient - $4,000
Outpatient - $2,000 |
80% |
60% |
80% |
60% |
Transplants
12-month waiting period
$250,000 lifetime maximum;
$50,000 per transplant donor organ procurement maximum; $2,500 per
transplant travel and lodging maximum |
80% |
60% |
80% |
60% |
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) |
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Pre-Existing Conditions |
A pre-existing
condition is one for which there has been
diagnosis, treatment (including the use of prescribed drugs), or
medical advice within the six month period prior to the effective date
of coverage or a condition for which symptoms existed within the six
month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
Pre-existing
conditions will not be
covered until a member has been continuously enrolled under this plan
for 9 (nine) months. In some cases, Asuris Northwest 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 (i.e., a plan that had benefits as
good or better than this plan), at any time during the 63
(sixty-three) day period immediately preceding the receipt date of the
application. |
* At this time, this
service is provided only by participating providers.
** At this time, this service is provided only by recognized providers.
Cost
Containment Provisions: All hospital and skilled nursing
facility admissions must be medically necessary. When outside the
service area, preadmission approval
should be obtained to ensure that full plans benefits will be
provided.
Emergency Care: In the event
of a medical emergency inside the service area, benefits will be provided at
the level specified for a Preferred Plan provider. Benefits for
recognized providers will be based on the recognized provider's actual
charge for the service. Outside the service area, benefits will be
provided at the level specified below.
Care Outside the Service Area:
All care received outside the
service area, whether or not a medical emergency, will be covered at
80% of the
allowed amount, except benefits for prescription drugs (HSA Healthplan
Comprehensive only) will be provided at the level specified. Any
balances of charges not covered by this plan will be your responsibility.
Annual Coinsurance Maximum: For medically necessary
services rendered by a Preferred Plan, participating, or recognized
provider in the service area, the benefits of this plan will be provided
at the percentage of the allowed amount as specified above after the
deductible has been met. Unless otherwise specified, all benefits are
subject to the annual deductible in addition to any
coinsurance. When you, or you and your family, have reached the annual
out-of-pocket maximum for
Preferred Plan or out-of-area provider services only, this plan will
provide benefits at 100% of the allowed amount for the remainder of the
calendar year for Preferred Plan or out-of-area providers only. Any balances of charges not covered by this plan will
be your, or you and your family's, responsibility to pay. Most services
provided by participating or recognized providers do not apply to the
annual out-of-pocket maximum.
Waiting Periods: No benefits
are provided for treatment relating to a transplant until you have
been covered under this or a prior plan with Asuris Northwest Health for 12 consecutive
months. No benefits will be provided for preexisting conditions until you have been covered under this plan for
nine consecutive months, unless you were continuously covered for at
least nine months under the immediately preceding creditable plan.
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Important
Information About This Benefit
Summary |
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This is a brief summary of benefits; it is
not a contract or a certificate of coverage. The complete terms of coverage
are determined by the carrier's contract. While we have accurately
represented the information in this Benefit Summary as of the time it was
published, should any discrepancies exist between this Benefit Summary and
the carrier's contract, the carrier's contract shall prevail. Please refer
to the carrier's contract for a complete statement of benefits including
waiting periods, limitations and exclusions.
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