03/01/2010 Council Packet - Laserfiche WebLink

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This plan is intended to qualify as a high deductible health plan that may be paired with an HSA; however, you should check with your tax advisor for guidance on your particular situation. The following summarizes your HealthPartners coverage. For exact terms and conditions, consult a Group Membership Contract, or call the Member Services Information Line at (952) 883 -7000 or call toll free at 1- 866 -443 -9352. Service Lifetime maximum Annual deductible Annual out -of- pocket maximum In- Network When care is provided by a network provider Unlimited $1,500 single contract; $3,000 family contract $3,000 single contract; $6,000 family contract Out -of- Network When care is provided by out -of- network providers $1,000,000 $3,000 single contract; $6,000 family contract $6,000 single contract $12,000 family contract Preventive Health Care ($300 annual maximum for out of network services does not apply to immunizations, prenatal & postnatal care.) • Prenatal & postnatal care, well -child care • Routine physical & eye examinations • Immunizations 100% coverage 100% coverage 100% coverage 60% coverage after deductible 60% coverage after deductible 60% coverage after deductible Office Visits • Illness or injury • Allergy injections • Physical, occupational & speech therapy • Chiropractic care (neuromusculo- skeletal conditions only) • Mental health care • Chemical health care 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 60% coverage after deductible 60% coverage after deductible 60% coverage after deductible 20 visits per year 60% coverage after deductible 20 visits per year 60% coverage after deductible 40 hours per year 60% coverage after deductible 130 hours per year Inpatient Hospital Care • Illness or injury • Mental health care • Chemical health care 80% coverage after deductible 365 days per period of confinement 80% coverage after deductible 365 days per period of confinement 80% coverage after deductible 365 days per .eriod of confinement 60% coverage after deductible 365 days per period of confinement 60% coverage after deductible 30 days per year 60% coverage after deductible 73 days per year Outpatient Care • Scheduled outpatient procedures 80% coverage after deductible • Outpatient Magnetic Resonance Imaging 80% coverage after deductible (MRI) and Computing Tomography (CT) Page 2 of 6 60% coverage after deductible 60% coverage after deductible C042 hstPs --00A-3(0(-0