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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 a Regence BlueShield PPO
plan provider.
Click
here to find out if your doctor belongs to the "Preferred"
network (in the "Plan:" drop-down box, choose "Preferred").
The percentages shown below are the amounts paid by Regence
BlueShield.
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
Provider |
Preferred Plan Provider |
Participating
Provider |
Annual Deductible PCY
HSA Healthplan
"Comprehensive" offers only one deductible choice for individual or
family coverage; choose one of the
two "HSA Healthplan" deductible options shown for individual or family coverage
the deductible applies to all expenses unless
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
Provider |
Preferred Plan Provider |
Participating
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
Provider |
Preferred Plan Provider |
Participating
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, Regence BlueShield 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. Preadmission approval
is required for all inpatient admissions outside the service area if
you seek care from providers who have not contracted with a Blue Cross
and/or Blue Shield plan, except for emergency services or maternity
admissions.
Emergency Care: Emergency benefits will be provided at
the level specified for a Preferred Plan provider. In the event of a
medical emergency, treatment by a provider not normally covered under
this plan will be recognized for a 24-hour period or for such
additional time as is reasonably required to come under the care of a
Preferred Plan provider. Benefits will be based on the recognized
provider's actual charge for the service.
Care Outside the Service Area:
All care received outside the
service area will be paid the same as in the service area if you use a
Preferred Plan or participating provider. Payment will be based on the
allowed amount. To receive the highest benefit level, you must receive
services from a Preferred Plan provider. If there is no Preferred Plan
provider network in an area, benefits will be provided for care received
from a participating provider at the level specified for Preferred Plan
providers. Benefits will be provided for
care received from a recognized provider at the level specified for
Preferred Plan providers only, if there is no local Blue Cross and/or Blue
Shield participating provider network in a particular area and for
medical emergencies. Call 1-800-810-BLUE (2583) for
names of Preferred Plan or participating providers with the local Blue
Cross and/or Blue Shield plan. When you need health care outside the
United States or its territories, call the BlueCard Worldwide Service Center at
1-800-810-BLUE or call collect at 1-804-673-1177. If you are admitted
to a hospital while traveling outside the service area, you must
contact Regence BlueShield within 24 hours to receive full plan
benefits. If you meet all requirements, inpatient benefits will be
provided at the level specified for Preferred Plan providers for like
services and supplies.
Annual Coinsurance Maximum: Benefits will be provided at the
percentages specified above until the annual coinsurance maximum has been
reached for the Preferred Plan network. When you have reached the
coinsurance maximum, this plan will provide benefits at 100% of the allowed amount for the
remainder of the calendar year for the services of Preferred Plan
providers only, unless otherwise specified. Any balances of charges not covered by
this plan will be your, or you and your family's, responsibility to pay.
Services provided by participating providers do not apply toward the
annual coinsurance 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 Regence BlueShield for 12 consecutive
months. No benefits will be provided for preexisting conditions,
including maternity, 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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