HSA Oregon: Health Savings Accounts in Oregon

LIFEWISE HEALTH SAVINGS ACCOUNTS (HSA)

WiseSavings HSA Plan

Deductible, coinsurance and copay represent what you pay. All coinsurance amounts are based on maximum allowable amounts. Benefits apply after calendar year deductible is met, unless otherwise noted as “no deductible,” “copay,” or “covered in full.” PCY = Per Calendar Year

	WiseSavings
	Preferred Providers	Non-Preferred & extended providers
Annual Deductible PCY (choose one)	Individual: $3,000 Family: $6,000*
Coinsurance¹ (what you pay)	20%	50%
Annual Coinsurance Maximum	Individual: $2,000 Family: $4,000	Unlimited
Out-of-Pocket Maximum	Annual deductible + coinsurance maximum
Office Visit Cost Share	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Lifetime Maximum	$2,000,000
Covered Services	Preferred Providers	Non-Preferred & extended providers
Preventive Care
Preventive Care Exams (routine medical exam, sports physical and women’s health exams/well baby)	No deductible applies, you pay 20%	Deductible applies first, then you pay 50%
Preventive Screenings (includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test)	Covered in full²
Immunizations
Professional Care
Office Visit including Urgent Care	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Other Outpatient and Inpatient Professional Services
Alternative Care
Spinal and Other Manipulations 12 visits PCY (visits shared with Acupuncture)	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Acupuncture 12 visits PCY (visits shared with Spinal and Other Manipulations)
Naturopathy
Diagnostic Services
Outpatient Diagnostic Imaging and Lab Services	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Mammography	Covered in full²
Pharmacy
Retail Pharmacy (30-day supply)	Deductible applies first, then you pay 20%; Preventive generic cardiac drugs are reimbursed at 100%²
Mail Service Pharmacy (90-day supply)	Not available
Emergency Care
Emergency Room Care (copay waived if direct admit to an inpatient facility)	Deductible applies first, then you pay 20%
Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit)
Facility Care
Inpatient Facility Care	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Outpatient Facility Care
Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees
Maternity
Maternity Care	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Vision Care
Routine Vision Exam	Not Covered
Vision Hardware
Other Services
Supplies, Equipment and Prosthetics $5,000 PCY	Deductible applies first, then you pay 20%	Deductible applies first, then you pay 50%
Home Health Care 130 visits PCY
Hospice Care Inpatient: 10 days, Respite: 240 hours per 6 months lifetime maximum
Rehabilitation (includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain) Outpatient: 20 visits PCY; Inpatient: 8 days PCY
Transplants (Organ & Bone Marrow) 12-month waiting period; $250,000 Lifetime Benefit
Alcohol Dependency Treatment	This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible 2 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance * Services for all family members covered under the same HSA-qualified plan get applied to the same deductible. The family deductible must be met before services are covered for any enrolled family members. This is only a summary of major benefits. It is not a contract.

Group Product

In order to quote Group Health Insurance Plans, we need to have a Group Census Form completed and returned to us. This form once downloaded may be faxed back to us at 541.284.2994.