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Asuris HSA Healthplan Benefits
For medically necessary services rendered
by a Preferred Plan, participating, or recognized provider, the benefits of
this plan will be provided at the percentage of the allowed amount as specified
below after the deductible has been met. Unless otherwise specified, all benefits
are subject to the annual deductible in addition to any coinsurance. When you
or you and your family have reached the annual out-of-pocket 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. Any balances of
charges not covered by this plan will be your responsibility to pay.
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HSA Healthplan |
Annual Deductible
Family deductible applies
when the subscriber and one or more dependents are enrolled. Prior to
benefits being paid for any family member, the entire family deductible
must be met. |
$2,500 or $3,500 single
$5,000 or $7,000 family |
| Lifetime maximum:
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$2,000,000 per individual |
| Benefits |
Preferred Plan Provider |
Participating Provider |
Annual Out-of-Pocket Coinsurance
Amount
The total amount
of coinsurance and deductible amount you or you and your family are responsible
to pay during a calendar year for covered services, after which the plan
will provide 100 percent of the allowed amount for the remainder of that
calendar year, unless otherwise specified. Any balances of charges not
covered by this plan will be you or your family’s responsibility
to pay. Family out-of-pocket amount applies when the subscriber and one
or more dependents are enrolled. Prior to benefits being paid at 100%
for any family member, the entire family out-of-pocket maximum must be
met. |
$5,000 member
$10,000 family |
No out-of-pocket maximum |
Professional Services
Including diagnostic x-ray
and laboratory. Coverage includes the services of physicians, osteopaths,
naturopathsic providers, and other eligible health care professional providers |
80%
(unless specified otherwise) |
60%
(unless specified otherwise) |
Hospital Facility (Inpatient
& Outpatient)
Including diagnostic
x-ray and laboratory |
80% |
60% |
Acupuncture
12 visits per calendar
year maximum |
80% |
60% |
Ambulance Services**
Ground services:
$2,000 per calendar year maximum |
80% |
80% |
| Blood Bank** |
80% |
80% |
Home Health and Hospice
Home Health – 130 visits per calendar year maximum
Hospice – 6 months maximum |
80% |
80% |
Home Medical Equipment
$2,500 per calendar year
maximum |
80% |
60% |
| Home Phototherapy |
80% |
80% |
Infusion Therapy
Growth hormone only treatment
is limited to $20,000 per calendar year |
80% |
60% |
Mammography
Routine mammograms not subject to deductible |
80% |
60% |
Mental Disorders
Inpatient - 8 days per calendar year
Outpatient - 12 visits per calendar year |
80% |
60% |
Occupational Injury (provided for the subscriber only)
Not subject to waiting
periods |
80% |
60% |
Phenylketonuria (PKU)
Formulas
Not subject to waiting
periods |
80% |
80% |
| Preventive Care (not subject to deductible) |
80% |
60% |
Prostate Cancer Screening
Routine prostate cancer screenings not subject to deductible |
80% |
60% |
| Prostheses and Orthotics
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80% |
60% |
Rehabilitation
Inpatient – $4,000 per calendar year maximum
Outpatient – $2,000 per calendar year maximum |
80% |
60% |
Skilled Nursing Facility
30 days per calendar year
maximum |
80% |
80% |
| Special Equipment and
Supplies |
80% |
80% |
Spinal Manipulations
10 visits per calendar year maximum |
80% |
60% |
Transplants
$250,000 lifetime maximum; 12-month
waiting period |
80% |
60% |
*At this time, these services are provided only by participating
providers.
**At this time, these services are provided only by recognized
providers.
Cost Containment Provisions: All hospital and skilled nursing facility admissions must be medically necessary. When outside the service area, preadmission approval should be obtained to ensure that full plan benefits will be provided.
Emergency Care: In the event of a medical emergency inside the service area, benefits will be provided at the level specified for a Preferred Plan provider. Benefits for recognized providers will be based on the recognized provider’s actual charge for the service. Outside the service area, benefits will be provided at the level specified below.
Care Outside the Service Area: All care received outside the service area, whether or not a medical emergency, will be covered at 80% of the allowed amount. Any balances of charges not covered by this plan will be your, or you and your family’s, responsibility.
Waiting Periods: No benefits are provided for treatment relating to a transplant until you have been covered under this or a prior plan with the Company (Asuris Northwest Health) for 12 consecutive months. No benefits will be provided for preexisting conditions 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.
This is a brief summary of benefits, it is
not a certificate of coverage. For full coverage provisions, including a description
of waiting periods, limitations, and exclusions, refer to the plan contract.
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Asuris NW Health 
