Coverage and Benefits

Example Highlights of a Typical HSA Plans Benefits

Practitioner Services

  In Network Out of Network
Office Visits 100% after deductible 80% after deductible
Preventative Care $500 per year per covered dependent child through end of calendar year in which child attains age one;
$300 maximum per covered person per calendar year.
Not subject to deductible or co-insurance.
Surgery100% after deductible80% after deductible
Radiology/Laboratory100% after deductible80% after deductible
Maternity100% after deductible80% after deductible
Photo: Female Doctor with X-ray

Hospital Services

  In Network Out of Network
Inpatient Care
(semi-private room or intensive care unit)		 100% after deductible 80% after deductible
Hospital Outpatient Care 100% after deductible 80% after deductible
Emergency Room 100% after deductible 80% after deductible
Pre-Admission Testing 100% after deductible 80% after deductible
Extended Care / Rehabilitation
(combined limit of 120 days per calendar year)		 100% after deductible 80% after deductible
Must begin within 14 days of preceding hospital stay. Requires Pre-approval
Hospice Care 100% after deductible 80% after deductible
Requires Pre-approval.
Photo: Female Surgeon

Other Services

  In Network Out of Network
Therapeutic Manuipulation 100% after deductible 80% after deductible
Limited to 30 visits per calendar year
Therapy Services Speech and cognitive rehabilitation therapies have a combined limit of 30 visits per calendar year.Occupational and physical therapies have a combined limit of 30 visits per calendar year. Chelation therapy, chemotherapy, dialysis treatment, radiation therapy and respiration therapy are covered as any other illness.Infusion therapy requires preapproval.
Non-biological Based Mental Illness and Substance Abuse
Inpatient		 100% after deductible 75% after deductible
Limited to 30 inpatient days per calendar year.
Non-biological Based Mental Illness and Substance Abuse
Outpatient		 100% after deductible 75% after deductible
Limited to 20 outpatient days per calendar year. One inpatient day may be exchanged for 2 outpatient visits.
Biological Based Mental Illness
Inpatient		 100% after deductible 80% after deductible
Biological-Based Mental Illness
Outpatient		 100% after deductible 80% after deductible
Durable Medical Equipment / Supplies 100% after deductible 80% after deductible
Prescription Drugs 80% after deductible 80% after deductible
Photo: Doctor Taking Female's Blood Pressure