2010 HSA Plan Design
|
| Covered Expense |
In-Network Benefit
(subject to deductible, unless noted) |
Out-of-Network Benefit
(up to R&C limit and subject to deductible) |
Network-Not-Available Benefit
(up to R&C limit and subject to deductible unless noted) |
| Allergy Injections, Serum, Testing and Treatment |
|
|
|
- Performed and billed in a PCP* office
|
90% |
70% |
80% |
- Performed and billed by a specialist in office
|
90% |
70% |
80% |
| Ambulance Service |
90% |
70% |
80% |
| Ambulatory Surgical Center |
90% |
70% |
80% |
Anesthetics, Oxygen, Transfusions
Anesthetics/oxygen and its administration; blood transfusions, including the cost of blood/plasma, unless there is no charge because it is replaced through a blood bank or in some other way |
90% |
70% |
80% |
Chiropractic Care
Services include office exams and spinal manipulations. Coverage is limited to 30 visits per covered person per year, combined in- and out-of-network. |
90% |
70% |
80% |
| Diagnostic X-rays and Lab Services |
|
|
|
- Performed and billed in a PCP* office
|
90% |
70% |
80% |
- Performed and billed in a Specialist office
|
90% |
70% |
80% |
- Performed and billed by an outside lab/facility
|
90% |
70% |
80% |
| Doctors' Office Visits |
|
|
|
|
90% |
70% |
80% |
|
90% |
70% |
80% |
| Drugs and Medicines administered in a doctor's office and health care facility (for others, benefits are payable under the Prescription Drug plan) |
|
|
|
- Performed and billed in PCP* office
|
90% |
70% |
80% |
- Performed and billed in Specialist office
|
90% |
70% |
80% |
- Performed and billed in Health care facility
|
90% |
70% |
80% |
| Durable Medical Equipment and Prosthetic Devices |
90% |
70% |
80% |
| Elective Abortion |
90% |
70% |
80% |
| Emergency Room Visits |
|
|
|
|
90% |
90% |
80% |
- For nonemergency conditions
|
90% |
70% |
80% |
Hearing Aids
Up to the calendar year limit of |
90% up to calendar year limit |
70% up to calendar year limit |
80% up to calendar year limit |
|
|
|
|
|
|
|
|
| Hemodialysis |
90% subject to precertification |
70% subject to precertification |
80% subject to precertification |
| Home Health Care/Nursing |
90% subject to precertification |
70% subject to precertification |
80% subject to precertification |
| Hospice Care |
90% subject to precertification |
70% subject to precertification |
80% subject to precertification |
| Hospital Services, Inpatient |
90% subject to precertification |
70% subject to precertification |
80% subject to precertification |
| Hospital Services, Outpatient |
90% |
70% |
80% |
Infertility Diagnosis and Treatment
Excludes in-vitro fertilization, other artificial insemination procedures, and experimental treatments. |
90% |
70% |
80% |
Maternity
Obstetrician or certified nurse-midwife services for pregnancy, childbirth, and pregnancy-related conditions |
90% |
70% |
80% |
- Inpatient hospital services including labor and delivery
|
90% Hospital stay subject to precertification |
70% Hospital stay subject to precertification |
80% Hospital stay subject to precertification |
- Outpatient diagnostic testing
|
90% |
70% |
80% |
| Mental Health and Substance Abuse Treatment |
|
|
|
|
90% |
50% |
80% |
- Outpatient and intermediate care
|
90% |
50% |
80% |
|
90% |
70% |
80% |
| Newborn Care, Inpatient |
90% |
70% |
80% |
| Organ Transplants |
|
|
|
- At designated Centers of Excellence
|
100% subject to precertification |
100% subject to precertification |
100% subject to precertification |
- At other transplant facilities
|
90% subject to precertification |
70% subject to precertification |
80% subject to precertification |
Orthotic Shoe Inserts
Limit of one set per calendar year |
90% |
70% |
80% |
| Preventive Care/Wellness (not subject to the deductible for in-network and network not-available services) |
|
|
|
- Routine physical at any age
|
100% |
Not covered |
100% |
- Routine gynecological exam and Pap smear
|
100% |
Not covered |
100% |
- Mammograms (no age related limits)
|
100% |
70% |
100% |
- Immunizations (excluding those for the sole purpose of travel outside the U.S., and allergy injections)
|
100% |
70% |
100% |
| Reconstructive Surgery |
90% |
70% |
80% |
| Second Surgical Opinions (not required) |
|
|
|
- Performed and billed in PCP* office visit
|
90% |
70% |
80% |
- Performed and billed in Specialist office visit
|
90% |
70% |
80% |
- Performed and billed by a Health care facility
|
90% |
70% |
80% |
Skilled Nursing Facility
Limit of 365 days per spell of illness |
90% |
70% |
80% |
| Sterilization, Elective |
90% |
70% |
80% |
| Surgery |
|
|
|
- Performed and billed by PCP* Doctor's office
|
90% |
70% |
80% |
- Performed and billed by Specialist Doctor's office
|
90% |
70% |
80% |
- Performed and billed by Outpatient facility
|
90% |
70% |
80% |
- Performed and billed by Hospital inpatient facility
|
90% |
70% |
80% |
Therapy Services
Occupational, physical, rehabilitation (including cardiac rehabilitation), and speech therapy. Coverage performed in a doctor’s office or outpatient facility is limited to 30 visits per covered person per year, combined in- and out-of-network. The limits are applied separately to each type of therapy. For example, you can have 30 occupational therapy visits and 30 physical therapy visits. |
|
|
|
- Performed and billed by PCP* Doctor's office.
|
90% |
70% |
80% |
- Performed and billed by Specialist Doctor's office
|
90% |
70% |
80% |
- Performed and billed by Outpatient facility
|
90% |
70% |
80% |
- Performed and billed by Hospital inpatient facility
|
90% |
70% |
80% |
