96 lines
10 KiB
Text
96 lines
10 KiB
Text
PLAN: Cigna 3500 HSA
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UID: Cigna 3500 HSA
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Category: Major Medical
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Type: PPO
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Marketing Name: Cigna - 3,500 HSA Plan
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Average Price: $933.13
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Short Description: An HSA-compatible PPO that helps you save on taxes while offering flexible access to care.
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Long Description: The Cigna 3500 HSA Plan lets you save money in a Health Savings Account while staying protected. You’ll pay 20% after your deductible, and preventive care is 100% covered. If you want to take control of your health spending and save on taxes, this plan is a great fit
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PRICING:
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Coverage 4: $1418.62
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Coverage 3: $863.78
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Coverage 2: $956.25
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Coverage 1: $493.90
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DETAILS:
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COVERAGE:
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Notes: Yes.
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If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
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Coverage Tier: All
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Emergency Room: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Monthly Premium: None
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Lifetime Maximum: No Maximum
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Professoinal Fees: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Referral Required: No
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Urgent Care Copay: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Employee Contribution: TBD by Group
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Employer Contribution: TBD by Group
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Inpatient Hospital Stay: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Habilitation - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Included no cost services: 0% Copay Telemedicine, Virtual Primary Care, Advocay Services
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Prescription Drug Deductible: You pay full price for prescriptions until your medical deductible is met.
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Habilitation - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Home heslth care - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Hospice services - In Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Specialist Copay - In Network: 20% after deductable met
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Emergency Medical Transporation: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Primary Care Copay - In Network: 20% after deductable met
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Your Rights to Continue Coverage: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explaination of benefits you will receivefor that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan.For more information about your rights, this notice, or assistance, contact: Acuity at 1-866-872-6356 or Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
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Deductible (Family) - In Network: 7000
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Home heslth care - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Hospice services - Out of Network: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is :Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
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Skilled nursing care - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Specialist Copay - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount.
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Your Grievance and Appeals Rights: Yes.
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If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
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Specialty Drugs - Network Provider: 50% coinsurance after deductable met
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Primary Care Copay - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount.
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Chiropractic Care Copay - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount.
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Deductible (Family) - Out of Network: 14000
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Deductible (Individual) - In Netwok: 3500
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Pregnancy office visits - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Rehabilitation Services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Skilled nursing care - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Durable medical equipment - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Chiropractic Care Copay - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Deductible (individual) - Out of Netwok: 7000
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Pregnancy office visits - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Rehabilitation Services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Specialty Drugs - Out of Network Provider: Not covered
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Durable medical equipment - Out of Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Out of Pocket Maximum (Family) - In Network: 13100
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Routine Preventive Services (Non-Diagnostic): No Member Cost Sharing - Deductible Waived
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Out of Pocket Maximum (family) - Out of Network: 26200
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Does this plan meet the Minimum Value Standards?: None
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Out of Pockert Maximum (Individual) - In Network: 6650
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Cildbirth/delivery facility services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Coinsurance % (Plan pays/Member Pays) - In Network: 80% / 20%%
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Does This Plan provide Minimum Essential Coverage?: For more information about limitations and exceptions, see the plan or policy document at https://www.acuity-grp.com
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Out of Pocket Maximum (Individual) - Out of Network: 13100
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Blood test to help diagnose a condition - In Network: You pay the full cost until of facility and professional service fees until your deductible is met, then 20% of the covered amount.
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Cildbirth/delivery facility services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Free Standing Lab & Diagnostic Services (Lab & x-ray): You pay the full cost until your deductible is met, then 0% of the covered amount.
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Preventative Care/Screening/Immunization - In Network: 0% Coinsurance
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Childbirth/delivery professional services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Coinsurance % (Plan pays/Member Pays) - Out of Network: 60% / 40%
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Blood test to help diagnose a condition - Out of Network: You pay the full cost facility and professional service fees until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Preventative Care/Screening/Immunization - Out of Network: Not Covered
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Childbirth/delivery professional services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Imaging tests like X-Rays, CT/PET Scans, or MRI's - In Network: You pay the full cost until of facility and professional service fees until your deductible is met, then 20% of the covered amount.
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Out Patient Services, Surgical Services (Procedure & Anesthesia): You pay the full cost until your deductible is met, then 20% of the covered amount.
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Imaging tests like X-Rays, CT/PET Scans, or MRI's - Out of Network: You pay the full cost facility and professional service fees until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Generic medication (30-day supply) from a pharmacy in your plan’s network: $15 copay
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Generic medication (31-90-day supply) from a pharmacy in your plan’s network: $45 copayemnt
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Inpatient mental/ behavioral health, and substance abuse services - In Network: You pay the full cost until of facility and professional service fees until your deductible is met, then 20% of the covered amount.
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Complex Diagnositc Services (CT, MRI, Ultra Sound, PET, Nuclear Med.) (Network): You pay the full cost until your deductible is met, then 20% of the covered amount.
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Outpatient mental/ behavioral health, and substance abuse services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee.
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Inpatient mental/ behavioral health, and substance abuse services - Out of Network: You pay the full cost facility and professional service fees until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Outpatient mental/ behavioral health, and substance abuse services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee.
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Brand-name medication that’s on your plan’s preferred list (30-day supply from an in-network pharmacy): $65 copay
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Brand-name medication that’s on your plan’s preferred list (31-90-day supply) from an in-network pharmacy): $90 copayemnt
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Brand-name medication that’s not on your plan’s preferred list (30-day supply) from an in-network pharmacy): $100 copay
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Brand-name medication that’s not on your plan’s preferred list (31-90-day supply) from an in-network pharmacy): $150 copayemnt
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