Health Net of California SimpleChoice HSA Plan Information
Plan Name:SimpleChoice HSA
Lifetime Maximum:$6 million
Annual Deductible:$4,000 single/ $8,000 family
Annual out-of-pocket maximum:Preferred Providers:$4,000 single/ $8,000 family,Non-preferred providers:$5,000 single/$10,000 family
Visit to physician: In-network:Covered in full after deductible is met, Out-of-Network:50%
X-ray and laboratory procedures: In-network:Covered in full after deductible is met, Out-of-Network:50%
Annual Routine Physical Exams:In-network:Covered in full after deductible is met, Out-of-Network:Not covered
Preventive care:Adult preventive care (age 19 and older) Yearly OB/GYN exam (breast and pelvic exams, Pap smears and mammography)/Yearly Prostate cancer screening and exam:In-network:$40 (Deductible waived), Out-of-Network:Not Covered
Child preventive care (newborns to age 18) Checkups, immunizations, vision and hearing exams:In-network:$40 (Deductible Waived), Out-of-Network: Not Covered
Maternity and pregnancy (Prenatal and postnatal office visits):Not Covered
Maternity care in hospital:Not Covered
Emergency and urgent care: Emergeny room (professional and facility charges):In-network:Covered in full after deductible is met, Out-of-Network:Covered in full after deductible is met
Urgent care center (facility charges):In-network:Covered in full after deductible is met, Out-of-Network:Covered in full after deductible is met
Ambulance:In-network:Covered in full after deductible is met, Out-of-Network:Covered in full after deductible is met
Outpatient Services (Outpatient Surgery):In-network: Out-of-Network:
Outpatient facility services:In-network:Covered in full after deductible is met, Out-of-Network:50%
Other Health Net of California health insurance plans:
