Medical Benefit Design In-Network. [NOTE – all charts have been updated to accurately reflect the 2019 medical plans] In-Network Plan Feature Health Reimbursement (HRA) Medical Plan Health Savings (HSA) Medical Plan Annual deductible $1,150 per person $2,300 max per family $1,500 employee only $3,000 if covering dependents Annual out-of-pocket maximum (with deductible) $3,300 per person $6,600 max per family $3,000 employee only$6,000 if covering dependents Preventive Care No charge No charge Primary Care Provider visits (non-preventive) $20 copay 10% after deductible Specialist visits (non- preventive) Tier I: 10% after deductible Tier II: 20% after deductible Tier I: 10% after deductible Tier II: 20% after deductible Lab and x-ray 20% after deductible 20% after deductible Alternative care (chiropractic, acupuncture) 20% after deductible Combined 12 visit limit per calendar year; all therapies Tier I, Tier II: 20% after deductibleCombined 12 visit limit per calendar year; all therapies Naturopathy Covered as Specialist Covered as Specialist Outpatient behavioral health care providers No charge No charge after deductible Outpatient hospital/surgery facility fees (except hospice, rehab) Tier I: 10% after deductible Tier II: 25% after deductible Tier I: 10% after deductible Tier II: 25% after deductible Inpatient hospital facility fees, including behavioral health Tier I: 10% after deductible Tier II: 25% after deductible Tier I: 10% after deductible Tier II: 25% after deductible Hospital physician fees Tier I: 10% after deductible Tier II: 20% after deductible Tier I: 10% after deductible Tier II: 20% after deductible Emergency room (waived if admitted) $250 copay 20% after deductible Urgent Care professional fees Tier I: 10% after deductible Tier II: 20% after deductible Tier I: 10% after deductible Tier II: 20% after deductible Maternity Pre-natal as Preventive Care Tier I, Tier II: No Charge Tier I, Tier II: No Charge Delivery and Post-natal Provider Care Tier I, Tier II: No Charge Tier I: 10% after deductible Tier II: 20% after deductible Maternity Hospital Stay and Routine Nursery Tier I: 10% after deductible Tier II: 25% after deductible Tier I: 10% after deductible Tier II: 25% after deductible
Medical Benefit Design In-Network. Plan Feature Health Reimbursement (HRA)
