Page 8 - 2020 DAN Benefits Enrollment
P. 8
Medical Plan Highlights
High Deductible
Enhanced Plan Standard Plan
Health Plan (HDHP)
Plan Feature* In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Contributions Per Semi Monthly Pay Period
Employee $101.00 $67.00 $38.50
Employee + Spouse $232.50 $166.50 $110.50
Employee + Child(ren) $207.00 $134.00 $88.00
Family $384.00 $273.00 $178.50
Deductible
Individual $500 $2,000 $1,000 $2,000 $2,000 $4,000
Family $1,000 $4,000 $2,000 $4,000 $4,000 $8,000
Company HSA Contribution
Individual/Family N/A N/A $500/$1,000
Out of Pocket Maximum
Individual $4,000 $8,000 $4,000 $8,000 $4,000 $12,000
Family $8,000 $16,000 $8,000 $16,000 $6,850 $24,000
Plan Feature
Plan Coinsurance 90% 70% 80% 60% 80% 60%
Preventive 100% Ded. and Coin. 100% Ded. and Coin. 100% Ded. and Coin.
Virtual Visits $0 Not Covered $0 Not Covered Ded. and Coin. Not Covered
Primary Care $30 Ded. and Coin. $30 Ded. and Coin. Ded. and Coin. Ded. and Coin.
Specialist $50 Ded. and Coin. $50 Ded. and Coin. Ded. and Coin. Ded. and Coin.
Inpatient Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin.
Outpatient Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin.
Emergency Room Copay $250 $250 Ded. and Coin.
8 2020 Beneits Enrollment
High Deductible
Enhanced Plan Standard Plan
Health Plan (HDHP)
Plan Feature* In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Contributions Per Semi Monthly Pay Period
Employee $101.00 $67.00 $38.50
Employee + Spouse $232.50 $166.50 $110.50
Employee + Child(ren) $207.00 $134.00 $88.00
Family $384.00 $273.00 $178.50
Deductible
Individual $500 $2,000 $1,000 $2,000 $2,000 $4,000
Family $1,000 $4,000 $2,000 $4,000 $4,000 $8,000
Company HSA Contribution
Individual/Family N/A N/A $500/$1,000
Out of Pocket Maximum
Individual $4,000 $8,000 $4,000 $8,000 $4,000 $12,000
Family $8,000 $16,000 $8,000 $16,000 $6,850 $24,000
Plan Feature
Plan Coinsurance 90% 70% 80% 60% 80% 60%
Preventive 100% Ded. and Coin. 100% Ded. and Coin. 100% Ded. and Coin.
Virtual Visits $0 Not Covered $0 Not Covered Ded. and Coin. Not Covered
Primary Care $30 Ded. and Coin. $30 Ded. and Coin. Ded. and Coin. Ded. and Coin.
Specialist $50 Ded. and Coin. $50 Ded. and Coin. Ded. and Coin. Ded. and Coin.
Inpatient Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin.
Outpatient Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin. Ded. and Coin.
Emergency Room Copay $250 $250 Ded. and Coin.
8 2020 Beneits Enrollment
