Page 8 - 2022 Washington Nationals Flipbook

80/60 HDHP w/ HEALTH SAVINGS ACCOUNT

HDHP with HSA

Plan Provision In-Network Out-of-Network

Company Contribution to HSA $600(employee only) / $1,200 (parent/child)
$1,320 (emp/spouse) / $1,440 (family)
Annual Deductible
1
Individual $1,400 $1,400
Family $2,800 $2,800
Out-of-Pocket Maximum (Excludes Deductible)
Individual $1,500 $3,600
Family $3,000 $6,000

Lifetime Maximum Unlimited

Preventive Care 100% Not covered

Primary Physician Office Visit 80%* 60%*

Specialist Office Visit 80%* 60%*

X-Ray and Lab 80%* 60%*

Inpatient Hospital Services 80%* 60%*

Outpatient Hospital Services 80%* 60%*

Urgent Care 80%* 60%*

Emergency Room Care 80%*

Click here for more detailed information on this available benefit option.

1 For those enrolled as a family under the HDHP, the family deductible and out-of-pocket maximums apply to the family on a combined basis.

Note: This is only a brief summary of your coverage. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary
(R&C) charges.

2022 Washington Nationals Benefit Guide Page 8