|
Consumer Choice 1 HSA Advance |
Consumer Choice 1
|
Consumer Choice 2 |
HSA Funding | $1,000 employee only
$2,000 family | Employee
election
| Employee
election
|
Deductible
|
Employee only: $1,650
Family: $3,300 |
Employee only: $3,600
Family: $7,200
|
In-Network
Annual Out-of-Pocket Maximum
(includes deductible) |
Employee only
$3,300
Family
$6,600
|
Employee only
$3,600
Family
$7,200 |
Out-of-Network
Annual Out-of-Pocket Maximum
(includes deductible) |
Employee only
$6,600
Family
$13,200
|
Employee only
$7,200
Family
$14,400 |
Coinsurance Paid After Deductible
(Applies to all professional services except those noted below.) |
You Pay 20%, plan pays 80%
| No coninsurance, plan pays 100% after the deductible is met |
Office Visit Copays
(Copays do not apply to deductible or out-of-pocket maximum) |
Subject to Deductible and Coinsurance |
Lab Work/ Professional Services | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance, then
Plan Pays 100% |
Emergency Room Visit Copayment | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance, then
Plan Pays 100% |
Preventive Care | You pay $0
|
Benefit Limits |
Maximum Lifetime Benefit
(Unless noted) | Unlimited |
Substance Abuse Treatment | Subject to Deductible and Coinsurance |
Mental Illness | Subject to Deductible and Coinsurance |
Chiropractic | Subject to Deductible and Coinsurance
|
Hearing Aids |
Up to $1,500 After the Deductible is Met Every 3 Years Per Person Covered |
Temporomandibular Joint Dysfunction and Related Disorders | Subject to Deductible and Coinsurance |
Physical, Occupational
and Speech Therapy | Subject to Deductible and Coinsurance
|
