Group Health Options, Inc. - 2011
Individual & Family HealthPays HSA
| |
HEALTHPAYS Health Savings Account Benefit Summary |
| |
Benefits
PCY=Per Calendar Year
|
ALLIANT
PLUS
IN-NETWORK |
ALLIANT PLUS
OUT-OF-NETWORK |
| |
Annual
Deductible
|
Individual: $2,750
Family: $5,500 |
| |
Coinsurance
(what you pay) |
20% |
40% |
| |
Out-Of-Pocket Maximum
(includes
deductible & coinsurance) |
Individual: $5,100
Family: $10,200 |
| |
BENEFITS (DEDUCTIBLE
DOES NOT APPLY) |
| |
Preventive Care
For children and
adults, including physicals and immunizations, as established in Group
Health's preventive care schedule. |
Covered in full |
40%
$300 individual/$600 family annual
benefit maximum |
| |
BENEFITS
(AFTER
DEDUCTIBLE, MEMBER PAYS) |
| |
Office
Visits (Includes mental health
outpatient services) |
20% |
40% |
| |
Manipulative Therapy
Limit total visits PCY to 10 combined for both in-
and out-of-network. |
20% |
40% |
| |
Acupuncture
|
20%
up to 8 visits PCY |
40% |
| |
Naturopathy
|
20%
up to 3 visits PCY |
40% |
| |
Maternity Care |
Not
Covered |
Not
Covered |
| |
Lab/X-Ray Services |
20% |
40% |
| |
Hospital
Visits - Inpatient
Hospital room and board; inpatient
surgery; anesthesia, intensive and coronary care, laboratory tests,
radiology services, drugs while in hospital. Includes mental health
inpatient treatment. Maternity care not covered. |
20% |
40% |
| |
Emergency Care |
20% |
40% |
| |
Devices, Equipment & Supplies (DME & Prosthetics) |
DME:
Covered at 50% up to $5,000 in charges ($2,500 max. benefit PCY)
Prosthetics: Covered at 50% up to $40,000 in charges ($20,000 max.
benefit PCY) |
| |
Vision Care
|
Not Covered |
Not Covered |
| |
Prescription Drugs
|
Not Covered |
Not Covered |
All Plans cover
on-the-job-injury-related health care costs for partners, proprietors, or
corporate officers who are not covered by a workers' compensation act, subject
to the plan's cost shares and benefit limitations.
Note: This is only a summary of the major benefits provided
by Group Health Options, Inc.. This is not a contract. See Benefit Booklet/Contract
for specific coverage information.
Questions? 800-877-8019
Copyright 2011, Green Financial, All Rights Reserved
