Page 10 - Work Life and Benefits Booklet 2020 SE

HSA Plan Glossary of Terms
The HSA plan you can pay for qualified healthcare expenses now and grow your savings for future
healthcare needs. This plan combines a High Deductible Health Plan (HDHP) with a special, tax- DEDUCTIBLE COINSURANCE
qualified savings account (HSA). You can contribute tax-free money to your HSA up to IRS
maximums. In addition, the money in your account is yours to pay for current healthcare expenses The amount of out-of- A cost sharing agreement
- or you can save toward future healthcare expenses. You have the freedom to choose your doctor pocket expenses that you between the insurance
without the requirement of selecting a PCP and you may self-refer to specialists and are not limited
to the physicians within the BCBSTX network. However, you will maximize your benefits and reduce must pay for before any company and the insured
your out-of-pocket costs if you choose a provider who participates in the BCBSTX network. The expenses are payable by where payment
calendar year deductible must be met before certain services are covered. the plan. responsibility is shared for
all claims covered by the
PPO & PPO High Plan On the HSA, you must policy, usually expressed as
The PPO plans give you the freedom to direct your own care, self-refer to a specialist and are not meet your deductible a percentage.
limited to the physicians within the BCBSTX network. However, you will maximize your benefits and before any benefits are
reduce your out-of-pocket costs if you choose a provider who participates in the BCBSTX network.
The calendar year deductible must be met before certain services are covered. paid including prescription
. drugs.
PLAN FEATURES HSA PPO OUT-OF-POCKET

Employee Premiums $ $$ COPAY MAXIMUM
Out-of-Pocket Costs $$$ $$ The flat dollar amount a The annual maximum
Contribution, Contribution, covered individual is amount of money you will
Cost Sharing Copay, Deductible, Copay, Deductible, required to pay for certain pay in addition to copays
Coinsurance Coinsurance services (could be before and deductibles. After you
Network Size   or after meeting any reach your out-of-pocket
maximum, benefits are
applicable deductible).
In-Network Benefits ✓ ✓ free (in-network only).
Non-Network Benefits ✓ ✓
Access to Providers Managed by You Managed by You
- Primary Care Physician Not Required Not Required
- Referral for Specialist Not Required Not Required

Educational Video
FINDING A MEDICAL PROVIDER
Go to www.bcbstx.com or call (800) 810-2583. Members refer to Deductibles, Copays, Coinsurance, and
the Blue Choice PPO network. Out-of-Pocket Maximums
http://video.burnhambenefits.com/terms/