Page 7 - Open Enrollment Guide Sample
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HSA Plan In-Network and Out-
of-Network
How the Health Savings Plan (HSA) Works This plan allows you both in-
network and out-of-network
You have an annual deductible. You pay the full cost for all physicians’ visits, access like the PPO plan. There
medical services, and prescriptions until you meet your annual deductible. is no change in the physician
There will be no copays. If you stay in-network, you pay the negotiated rate and provider network. You will
on these expenses. Once you meet the appropriate in-network or out-of- have the same access to your
doctors and hospitals as you do
network deductible, coverage is shared with the company in a coinsurance in the current PPO plan. You will
(80%/20%) arrangement until an out-of-pocket maximum is met. Under the receive better discounts and pay
HSA plan, if you stay in-network, the most you will pay for claims in a year is less out-of-pocket by remaining
$2,550 as an individual or $5,100 for all other coverage levels. Refer to page in-network.
14. Additionally, preventive care is covered at 100% when care is received Physicians Office Visits
through an in-network physician or facility. Show your Anthem member ID
card at the physician’s ofice.
Once you meet the out-of-pocket maximum the company will pay 100% of When your provider bills Anthem
the cost for the rest of the year. If you go out-of-network, the plan will cover you will get the discounted rate
the reasonable and customary rate. You will be responsible for the deductible, which will apply towards your
coinsurance, and any amounts over the reasonable and customary rate on all deductible. Most physicians and
other healthcare providers are
out-of-network services. very familiar with HSA plans and
will submit the claim to Anthem
Employer Contribution for Healthcare Bank Account and bill you.
For those electing the HSA and opening up a healthcare bank account,
[Client] will put money into your healthcare bank account to use toward your
deductible.
Employer Contribution
Individual $300
Family $600
For individuals who open up an account, [Client] will fund the account each
pay period. You will receive $11.54 per pay period as an individual or $23.08
per pay period for all other coverage levels.
Bi-Weekly Medical Contributions
HSA
Team Member $45.02
Team Member + Spouse $144.08
Team Member + Child(ren) * $108.06
Family ** $189.11
* Team member + Child(ren) includes the Team member plus any number of children 2016 Open Enrollment
** Family includes the Team member, a Spouse, and any number of children
HSA Plan In-Network and Out-
of-Network
How the Health Savings Plan (HSA) Works This plan allows you both in-
network and out-of-network
You have an annual deductible. You pay the full cost for all physicians’ visits, access like the PPO plan. There
medical services, and prescriptions until you meet your annual deductible. is no change in the physician
There will be no copays. If you stay in-network, you pay the negotiated rate and provider network. You will
on these expenses. Once you meet the appropriate in-network or out-of- have the same access to your
doctors and hospitals as you do
network deductible, coverage is shared with the company in a coinsurance in the current PPO plan. You will
(80%/20%) arrangement until an out-of-pocket maximum is met. Under the receive better discounts and pay
HSA plan, if you stay in-network, the most you will pay for claims in a year is less out-of-pocket by remaining
$2,550 as an individual or $5,100 for all other coverage levels. Refer to page in-network.
14. Additionally, preventive care is covered at 100% when care is received Physicians Office Visits
through an in-network physician or facility. Show your Anthem member ID
card at the physician’s ofice.
Once you meet the out-of-pocket maximum the company will pay 100% of When your provider bills Anthem
the cost for the rest of the year. If you go out-of-network, the plan will cover you will get the discounted rate
the reasonable and customary rate. You will be responsible for the deductible, which will apply towards your
coinsurance, and any amounts over the reasonable and customary rate on all deductible. Most physicians and
other healthcare providers are
out-of-network services. very familiar with HSA plans and
will submit the claim to Anthem
Employer Contribution for Healthcare Bank Account and bill you.
For those electing the HSA and opening up a healthcare bank account,
[Client] will put money into your healthcare bank account to use toward your
deductible.
Employer Contribution
Individual $300
Family $600
For individuals who open up an account, [Client] will fund the account each
pay period. You will receive $11.54 per pay period as an individual or $23.08
per pay period for all other coverage levels.
Bi-Weekly Medical Contributions
HSA
Team Member $45.02
Team Member + Spouse $144.08
Team Member + Child(ren) * $108.06
Family ** $189.11
* Team member + Child(ren) includes the Team member plus any number of children 2016 Open Enrollment
** Family includes the Team member, a Spouse, and any number of children
