Get documents about "HEALTH SAVINGS ACCOUNT (HSA) HSA EMPLOYER CONTRIBUTION $ 800
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University of Toledo -- Medical Mutual CDHP
Effective Date: 1/1/2010
Medical Mutual of Ohio - SuperMed Plus
PLAN DESIGN & BENEFITS
(this is only a summary, please refer to plan document for details)
PROVIDED BY MEDICAL MUTUAL OF OHIO
HEALTH SAVINGS ACCOUNT (HSA)
A Health Savings Accounts (HSA), is a health insurance plan that gives you more control over how you spend, or save, your health care dollars. Its a medical benefits plan AND savings
account, all in one. With a HSA, you get the protection of a medical and prescription drug benefits plan, PLUS you get a tax advantaged health savings account that you can use to help
pay for qualified expenses. The accounts are tax-advantaged and interest bearing, giving you a choice of spending and savings. The University will contribute the stated amount below,
and then you have the option of contributing, pre-tax, additional dollars, up to the amount of the annual IRS limit for a HSA. At the end of the year, money left in the account rolls over to
the next year.
$ 800 Single
HSA EMPLOYER CONTRIBUTION
$ 1,600 Family
DEDUCTIBLE (per calendar year) $1,200 Single/$2,400 Family
Maximum Out-of-Pocket (per calendar year) $2,000 Single/$4,000 Family
-Includes Deductible
Medical Lifetime Maximum TIER 1 TIER 2 & TIER 3
no limit $2,000,000
Dependent Age Limit 19 Dependent/25 Student as long as full-time student and unmarried (Removal upon End of Calendar Year in which age is reached)
TIER 1 BENEFITS TIER 2 TIER 3
PREVENTIVE CARE - Deductible Waived UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Routine Adult Physical Exams Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
1 exam per 12 months
Routine Well Child Exams/Immunizations Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
7 exams in the first 12 months of life,
3 exams in the second 12 months of life;
3 exams in the third 12 months of life;
1 exam per 12 months thereafter.
Routine Gynecological Care Exams Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
Includes Pap smear and related lab fees
Routine Mammograms Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
For covered females age 40 and over.
Colorectal Cancer Screening Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
Routine Digital Rectal Exam / Prostate- Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
specific Antigen Test
Routine Eye Exam/Routine Hearing Exam
1 routine eye exam every 12 months Not Applicable Covered 90%; deductible waived Covered 70%; deductible waived
1 routine hearing exam per 24 months. Covered 100%; deductible waived Covered 90%; deductible waived Covered 70%; deductible waived
TIER 1 BENEFITS TIER 2 TIER 3
PHYSICIAN AND DIAGNOSTIC SERVICES UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Office Visits to Physician Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
Includes services of a primary care physician or
specialist
Allergy Testing/Injections Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
Diagnostic Laboratory and X-ray Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
TIER 1 BENEFITS TIER 2 TIER 3
EMERGENCY MEDICAL CARE UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Urgent Care Provider Not Applicable Covered 90%; after deductible Covered 90%; after deductible
(benefit availability may vary by location)
Non-Urgent Use of Urgent Care Provider Not Covered Not Covered Not Covered
Emergency Room Covered 100% after deductible Covered 90%; after deductible Covered 90%; after deductible
Non-Emergency care in an Emergency Not Covered Not Covered Not Covered
Room
90% Emergency after deductible;
Ambulance Not Applicable Covered 90%; after deductible
70% Non-Emergency after deductible
TIER 1 BENEFITS TIER 2 TIER 3
HOSPITAL CARE UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Inpatient Coverage Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's inpatient
stay.
Inpatient Maternity Coverage Not Applicable Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's inpatient
stay.
Outpatient Hospital (including surgery) Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's outpatient
visit.
University of Toledo -- Medical Mutual CDHP
Effective Date: 1/1/2010
Medical Mutual of Ohio - SuperMed Plus
PLAN DESIGN & BENEFITS
(this is only a summary, please refer to plan document for details)
PROVIDED BY MEDICAL MUTUAL OF OHIO
TIER 1 BENEFITS TIER 2 TIER 3
MENTAL HEALTH SERVICES UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Inpatient Not Applicable Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's inpatient
stay.
Outpatient Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's outpatient
visit.
TIER 1 BENEFITS TIER 2 TIER 3
ALCOHOL/DRUG ABUSE SERVICES UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Inpatient Not Applicable Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all covered
benefits incurred during a member's inpatient
stay.
Outpatient Not Applicable Covered 90%; after deductible Covered 70%; after deductible
The member cost sharing applies to all
Covered Benefits incurred during a member's
outpatient visit.
TIER 1 BENEFITS TIER 2 TIER 3
OTHER COVERED SERVICES UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
Convalescent Facility/Skilled Nursing Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
Limited to 120 days per calendar year.
Semi-private room rate
Home Health Care Not Applicable Covered 90%; after deductible Covered 70%; after deductible
Limited to 120 visits per calendar year.
Hospice Care - Inpatient/Outpatient Not Applicable Covered 90%; after deductible Covered 70%; after deductible
Private Duty Nursing - Outpatient (Limited Not Applicable Covered 90%; after deductible Covered 70%; after deductible
to 70 eight hour shifts per calendar year)
Each period of private duty nursing of up to 8
hours will be deemed to be one private duty
nursing shift.
Outpatient Short-Term Rehabilitation Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
Includes Chiropractic Care, Speech, Physical,
Occupational, and Spinal Manipulation
Therapy, limited to $1,500 per member per
calendar year.
Durable Medical Equipment Covered 100% after deductible Covered 90%; after deductible Covered 70%; after deductible
Limited to $7,500 per calendar year
TIER 1 BENEFITS TIER 2 TIER 3
PHARMACY UNIVERSITY MEDICAL CENTER IN-NETWORK OUT-OF-NETWORK
SERVICES
When you fill prescriptions you will pay the cost of your prescriptions until the deductible has been met. Once the deductible is met you pay either the
copay that is detailed below. Once the out-of-pocket maximum has been met, all prescriptions are covered at 100%.
30 Day Supply - $5/20%/30% After combined medical/Rx plan After combined medical/Rx plan Not Applicable
deductible, then $5 copay for generic deductible, then $5 copay for generic
drugs, 20% copay for formulary brand- drugs, 20% copay for formulary brand-
name drugs ($80 Max per name drugs ($80 Max per
prescription), and 30% copay for non- prescription), and 30% copay for non-
formulary brand-name drugs up to a formulary brand-name drugs up to a
30 day supply at University of Toledo 30 day supply at participating
Pharmacies. pharmacies.
90 Day Supply - $10/20%/30% After combined medical/Rx plan After combined medical/Rx plan Not Applicable
deductible, then $10 copay for generic deductible, then $10 copay for generic
drugs, 20% copay for formulary brand- drugs, 20% copay for formulary brand-
name drugs ($200 Max per name drugs ($200 Max per
prescription), and 30% copay for non- prescription), and 30% copay for non-
formulary brand-name drugs up to a formulary brand-name drugs up to a
90 day supply from University of 90 day supply
Toledo Pharmacies.
Preventive Medication Feature
The Preventive Medication Feature provides coverage for certain medications without first meeting your deductible.
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