| |
HSA Value |
| Standard HSA Plan |
In Network |
Out of Network |
| Plan year deductible |
$2,800 (individual) /
$5,600 (family) |
| Out-of-Pocket Maximum (after deductible) |
$2,200 (Individual) / $4,400 (Family) |
No maximum |
| Preventive Care |
| Annual women's exam - pap, pelvic, breast |
50%* |
50% |
| Women's routine mammogram |
50%* |
50% |
| Well-baby care |
50%* |
50% |
| Routine physical exams |
50%* |
50% |
| Immunizations |
50%* |
50% |
| Professional Services |
| Office Visits |
50% |
50% |
Alternative care ($1,000 per plan year
limit)
Chiropractic, naturopathic and acupuncture |
50% |
50% |
| Facility and Ancillary Services |
| Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care |
50% |
50% |
| Maternity - All pre/post office visits and doctor delivery; hospital charges |
50% |
50% |
| Mental Health ($2,500 maximum in a 12-month period)Inpatient, outpatient, residential combined |
50% |
50% |
| Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare |
50% |
50% |
| Emergency Services |
| Urgent Care |
50% |
50% |
| Emergency room (deductible applies) |
50% |
50% |
| Ambulance ($5,000 per plan year limit) |
50% |
| Other Benefits |
| Prescription services |
50% |
| Lifetime benefit maximum |
$2,000,000 |
$250,000 |
| Accident benefit |
Paid as any other illness subject to deductible/co-insurance |
| *The plan deductible is waived for these
services. |
LifeWise
HSA Plans
