Page 55 - Benefits Summary 2018-2019

Benefits In-Network Out-of-Network
Hospital Services
After the plan deductible is met, After the plan deductible is met,
Inpatient hospital services You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Inpatient Professional Services After the plan deductible is met, After the plan deductible is met,
 For services performed by Surgeons, You pay 0% You pay 30%
Radiologists, Pathologists, Anesthesiologists, Plan pays 100% Plan pays 70%
and Hospital Based Physician
After the plan deductible is met, After the plan deductible is met,
Outpatient hospital services You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Outpatient professional services After the plan deductible is met, After the plan deductible is met,
 For services performed by Surgeons, You pay 0% You pay 30%
Radiologists, Pathologists, Anesthesiologists Plan pays 100% Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Skilled nursing facility care You pay 0% You pay 30%
 60 days per plan year maximum
Plan pays 100% Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Hospice care You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Home health care
 60 visits per plan year maximum After the plan deductible is met, After the plan deductible is met,
You pay 0%
You pay 30%
 The limit is not applicable to mental health and Plan pays 100% Plan pays 70%
substance use disorder conditions.
Mental Health and Substance Use Disorder
After the plan deductible is met,
Inpatient mental health After the plan deductible is met,
 Includes Residential Treatment Plan pays 100% You pay 30%
Plan pays 70%
Outpatient mental health – Physician’s Office After the plan deductible is met, After the plan deductible is met,
 Includes Individual, Intensive Outpatient, You pay 0% You pay 30%
Behavioral Telehealth Consultation, and Group Plan pays 100% Plan pays 70%
Therapy
Outpatient mental health – all other services
 Includes Partial Hospitalization After the plan deductible is met, After the plan deductible is met,
 Includes Individual, Intensive Outpatient, Plan pays 100% You pay 30%
Behavioral Telehealth Consultation, and Group Plan pays 70%
Therapy
After the plan deductible is met,
Inpatient substance use disorder After the plan deductible is met,
 Includes Residential Treatment Plan pays 100% You pay 30%
Plan pays 70%
Outpatient substance use disorder – Physician’s
Office After the plan deductible is met, After the plan deductible is met,
 Includes Individual, Intensive Outpatient, You pay 0% You pay 30%
Behavioral Telehealth Consultation, and Group Plan pays 100% Plan pays 70%
Therapy
Outpatient substance use disorder – all other
services
 Includes Partial Hospitalization After the plan deductible is met, After the plan deductible is met,
You pay 30%
 Includes Individual, Intensive Outpatient, Plan pays 100% Plan pays 70%
Behavioral Telehealth Consultation, and Group
Therapy
Therapy Services

11/1/2018
ASO
Health Savings Account Open Access Plus - HSA OAP 11-2018 - 7900133. Version# 12

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