Page 9 - Work Life and Benefits Booklet 2018 - SS

HSA Plan Glossary of Terms
With 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, DEDUCTIBLE COINSURANCE
tax-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 - or you can save toward future healthcare expenses. You have the freedom to choose The amount of out-of- A cost sharing agreement
your doctor without the requirement of selecting a PCP and you may self-refer to specialists and pocket expenses that between the insurance
are not limited to the physicians within the BCBSTX network. However, you will maximize your you must pay for before company and the insured
benefits and reduce your out-of-pocket costs if you choose a provider who participates in the any expenses are payable where payment
BCBSTX network. The calendar year deductible must be met before certain services are covered. by the plan. responsibility is shared

PPO & PPO High Plan for all claims covered by
The PPO plans give you the freedom to direct your own care, self-refer to a specialist and are not the policy, usually
limited to the physicians within the BCBSTX network. However, you will maximize your benefits expressed as a
and reduce your out-of-pocket costs if you choose a provider who participates in the BCBSTX percentage.
network. The calendar year deductible must be met before certain services are covered.
COPAY OUT-OF-POCKET
PLAN FEATURES HSA PPO PPO High MAXIMUM

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