Page 7 - 2015 OE Sample Guidebook
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MEDICAL PLAN SUMMARIES
Option 1—HRA Plan Option 2—HSA Plan
Plan Features
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
Individual $1,250 $2,500 $2,250 $4,500
Family $2,500 $5,000 $4,500 $9,000
Out-of-Pocket Limit (includes the deductible)
Individual $2,500 $5,000 $4,500 $9,000
Family $5,000 $10,000 $9,000 $18,000
Lifetime Maximum Unlimited Unlimited
Hospital Services
Inpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Outpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Emergency Room $200 copay, then 80% after ded. 80% after ded.
Physician Visits and Outpatient Facility Services
Primary Care (Family or General Practitioner, Internal $25 copay 60% after ded. 80% after ded. 60% after ded.
Medicine, Pediatrician, OB/GYN)
Specialist Visits $50 copay 60% after ded. 80% after ded. 60% after ded.
Preventive Care 100% No coverage 100% No coverage
Urgent Care 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Lab Services 80% after ded. 60% after ded. 80% after ded. 60% after ded.
X-Ray/Radiology 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Chiropractic Care 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Physical, Occupational, and Speech Therapy 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Mental Health and Substance Abuse
Inpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Outpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Private Duty Nursing 4 Visits Maximum Per Month 4 Visits Maximum Per Month
Onsite Medical Services
In addition to providing healthcare insurance beneits, [Client] There is no cost to you to see the
offers worksite access to nurse practitioners as part of our Wellness nurse practitioner (no copay, no
Initiative. This beneit is intended to provide [Client] regular bill)
employees convenient access to a licensed, healthcare professional in Services are delivered by licensed
order to seek wellness, itness, and medical counseling, assessment healthcare professionals employed
of health concerns or conditions, assistance in inding a primary or by local reputable medical clinics
specialty physician for medical follow-up, and assistance in obtaining Employees will be able to receive
prescriptions. While the nurse practitioner will be able to offer on-site healthcare without taking
assessment of many health conditions, the service is not intended as signiicant time away from work
a substitute to your primary care physician. This beneit offers you
several advantages: [Client] is committed to an increase
in the hours of availability of this
service in 2014!
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Option 1—HRA Plan Option 2—HSA Plan
Plan Features
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
Individual $1,250 $2,500 $2,250 $4,500
Family $2,500 $5,000 $4,500 $9,000
Out-of-Pocket Limit (includes the deductible)
Individual $2,500 $5,000 $4,500 $9,000
Family $5,000 $10,000 $9,000 $18,000
Lifetime Maximum Unlimited Unlimited
Hospital Services
Inpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Outpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Emergency Room $200 copay, then 80% after ded. 80% after ded.
Physician Visits and Outpatient Facility Services
Primary Care (Family or General Practitioner, Internal $25 copay 60% after ded. 80% after ded. 60% after ded.
Medicine, Pediatrician, OB/GYN)
Specialist Visits $50 copay 60% after ded. 80% after ded. 60% after ded.
Preventive Care 100% No coverage 100% No coverage
Urgent Care 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Lab Services 80% after ded. 60% after ded. 80% after ded. 60% after ded.
X-Ray/Radiology 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Chiropractic Care 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Physical, Occupational, and Speech Therapy 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Mental Health and Substance Abuse
Inpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Outpatient 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Private Duty Nursing 4 Visits Maximum Per Month 4 Visits Maximum Per Month
Onsite Medical Services
In addition to providing healthcare insurance beneits, [Client] There is no cost to you to see the
offers worksite access to nurse practitioners as part of our Wellness nurse practitioner (no copay, no
Initiative. This beneit is intended to provide [Client] regular bill)
employees convenient access to a licensed, healthcare professional in Services are delivered by licensed
order to seek wellness, itness, and medical counseling, assessment healthcare professionals employed
of health concerns or conditions, assistance in inding a primary or by local reputable medical clinics
specialty physician for medical follow-up, and assistance in obtaining Employees will be able to receive
prescriptions. While the nurse practitioner will be able to offer on-site healthcare without taking
assessment of many health conditions, the service is not intended as signiicant time away from work
a substitute to your primary care physician. This beneit offers you
several advantages: [Client] is committed to an increase
in the hours of availability of this
service in 2014!
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