|
PCY = per calendar year |
|
Plan Name |
HealthPays HSA |
|
Name of Network |
Alliant Plus
In-Network Provider |
Alliant Plus
Out-of-Network Provider |
Annual Deductible
PCY
the deductible applies to all expenses unless otherwise specified |
Individual
Coverage
$2,000
Family Coverage
$4,000 |
Annual Coinsurance Maximum
PCY |
Individual
Coverage
$3,100
Family Coverage
$6,200 |
Out-of-Pocket Maximum
PCY;
includes annual
deductible and coinsurance maximum; once the out-of-pocket maximum is
met, providers are covered in full |
Individual
Coverage
$5,100
Family Coverage
$10,200 |
|
Lifetime Maximum |
$2 million per individual |
|
Office Visits |
90% |
80% |
Preventive Care
No deductible
For children and
adults, including physicals and immunizations, as established in Group
Health's
preventive care schedule |
90%
no maximum benefit |
80%
$300 per person
$600 per family
maximum PCY |
Manipulative Therapy
10 visits limit PCY |
90% |
80% |
Acupuncture
In-Network: 8 visits limit PCY
Out-of-Network: no limit |
90% |
80% |
Naturopathy
In-Network: 3 visits limit PCY
Out-of-Network: no limit |
90% |
80% |
|
Maternity Care |
Not covered |
Mental Health Services
Inpatient - 12 days limit PCY
Outpatient - 12 visits limit PCY |
90% |
80% |
Rehabilitation Services - Inpatient
Inpatient
physical, occupational, and restorative speech-therapy services
combined; 30 days limit PCY |
90% |
80% |
|
 |
|
PCY = per calendar year |
|
Plan Name |
HealthPays HSA |
|
Name of Network |
Alliant Plus
In-Network Provider |
Alliant Plus
Out-of-Network Provider |
Rehabilitation Services - Outpatient
Outpatient physical,
occupational, and restorative speech-therapy services combined; 60
visits limit PCY |
90% |
80% |
Lab & X-Ray Services
Outpatient services |
90% |
80% |
Hospital Care - Inpatient
Hospital
room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital |
90% |
80% |
|
Prescription Drugs - Outpatient |
Not covered |
Ambulance Services
Emergency ground/air transportation |
90% |
80% |
Ambulance Services
Non-emergency ground/air
interfacility transfer |
90% for Group
Health-initiated transfers,
except hospital-to-hospital transfers
covered in full |
80% |
Chemical Dependency Treatment - Inpatient
Limited to
acute detoxification only |
90% |
80% |
Chemical Dependency Treatment - Outpatient
Limited to
diagnostic evaluation only |
90% |
80% |
Devices, Equipment & Supplies
(for home use)
Orthopedic
appliances, durable medical
equipment, glucose monitors, ostomy supplies, etc. |
50%
Maximum benefit is $2,500 PCY for all except
ostomy supplies and prosthetics;
maximum benefit PCY for ostomy supplies/prosthetics is $20,000 |
Emergency Care
Provided
at Group Health or
Group-Health designated hospital emergency
departments |
90% |
|
|
|
PCY = per calendar year |
|
Plan Name |
HealthPays HSA |
|
Name of Network |
Alliant Plus
In-Network Provider |
Alliant Plus
Out-of-Network Provider |
Emergency Care
Provided
at non-Group Health or
non-Group Health designated facilities |
90% |
Hearing Exams (routine)
To
determine hearing loss |
90% |
80% |
Home Health Care
No visits limit |
90% |
80% |
|
Hospice |
90% |
80% |
Organ Transplant
Six month benefit waiting
period |
Covered subject to
your applicable cost share up to $250,000
lifetime maximum (including
organ acquisition, matching, and donor costs
up to $50,000) |
Skilled Nursing Facility Care
60 days limit PCY |
90% |
80% |
Tobacco Cessation Sessions
Individual/group sessions |
100% |
Not covered |
Tobacco Cessation Pharmacy
Approved
pharmacy products |
100% when
prescribed as part of a Group Health-designated tobacco cessation
program and dispensed through the Group Health mail order service |
Not covered |
|
Vision Care - Routine Eye Exam |
Not covered |
|
Vision Care - Hardware |
Not covered |
|
Work-Related Conditions |
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 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, Group 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. |
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