Health Net of California SmartChoice HSA Plan Information
Plan name: SmartChoice HSA
Annual deductible:
Per Member: $2,500 (All benefits including pharmacy are subject to the deductible,except preventive care)
Per Family: $5,000 (No benefits until family deductble is met)
Annual out-of-pocket maximum:
Per Member: $2,500 (All benefits including pharmacy are subject to the deductible,except preventive care)
Per Family: $10,000 combined in- and out-of-network (includes deductible)
Lifetime Maximum: $6 million
Visit to physician:
In-Network Provider:30%
Out-of-Network Provider:50%
X-ray and laboratory procedures:
In-Network Provider:30%
Out-of-Network Provider:50%
Preventive care:
Routine physical exams,including routine lab and X-ray services:
In-Network Provider: $70 copay (deductible waived)
Out-of-NetworkProvider:Not covered
Annual OB/GYN exam (breast and pelvic exams,cervical cancer screening and mammography):
In-Network Provider: $35 copay(deductible waived)
Out-of-Network Provider: Not covered
Prostate cancer screening and exam:
In-Network Provider: $35 copay (deductible waived)
Out-of-Network Provider: Not covered
Immunizations Standard: Not covered
To meet foreign travel or occupational requirements: Not covered
Child preventive care (newborn to age 18); checkups,vision and hearing exams, Immunizations:
In-Network Provider:$35 copay (deductible waived)
Out-of-Network Provider: Not covered
Child preventive care Immunizations:
In-Network Provider:$35 copay (deductible waived)
Out-of-Network Provider: Not coveredOut-of-Network Provider:
Allergy testing and injection services:
In-Network Provider: 30%
Out-of-Network Provider:50%
Maternity and pregnancy:
Prenatal and postnatal office visits: Not covered
Maternity care in hospital: Not covered
Emergency and urgent care:
Emergency room (professional and facility charges):
In-Network Provider: 30%
Out-of-Network Provider: 30%
Deductible if not admitted to inpatient facility: $70 (Calendar year deductible applies)
Urgent care center (facility charges):
In-Network Provider: 30%
Out-of-Network Provider: 30%
Ambulance:
In-Network Provider: 30%
Out-of-Network Provider: 30%
Inpatient Hospital services (non-emergency care):
Physician/surgeon and anesthetics services:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Organ and bone marrow transplants (nonexperimental and noninvestigational):
In-Network Provider: 30%
Out-of-Network Provider: Not covered
Alcohol detoxification:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Hospital and skilled nursing facility (facility charges):
Inpatient, semiprivate hospital room or intensive
care unit with ancillary services (unlimited,
except for mental health and substance abuse treatment):$250 Per Admission Copay
In-Network Provider: 30%
Out-of-Network Provider: 50%
Outpatient surgery:$250 Per Admission Copay
In-Network Provider: 30%
Out-of-Network Provider: 50%
Skilled nursing facility (100-day annual limit combined in- and out-of-network):
In-Network Provider: 30%
Out-of-Network Provider: 50%
Reproductive health:
Sterilization:
In-Network Provider: 30%
Out-of-Network Provider: Not Covered
Other services:
Home health services limited to 90 visits per calendar year combined in- and out-ofnetwork:
In-Network Provider: 30%
Out-of-Network Provider: 50% ($75 maximum payable per day)
Hospice services:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Rehabilitative therapy (includes physical, speech,
occupational, respiratory and cardiac therapy) Limited to 20 visits per calendar year combined in- and out-ofnetwork:
In-Network Provider: 30%
Out-of-Network Provider: 50% ($25 maximum payable per visit)
Chiropractic care:
In-Network Provider: 50% ($20 maximum payable per visit. 12 visits maximum per calendar year)
Out-of-Network Provider: Not covered
Acupuncture: Not covered
Mental health services for severe conditions:
In-Network Provider: $250 Per Admission Copay plus 30% Inpatient/ 30% Outpatient
Out-of-Network Provider: $250 Per Admission Copay plus 50% inpatient / 50% Outpatient
Mental health services for nonsevere conditions:
In-Network Provider: $250 Per Admission Copay plus 30% Inpatient/ 30% Outpatient
Out-of-Network Provider: $250 Per Admission Copay plus 50% inpatient / 50% Outpatient
Durable medical equipment (including foot orthotics):
In-Network Provider: 50% ($2,000 maximum payable per calendar year)
Out-of-Network Provider: Not covered
Corrective footwear:
In-Network Provider: 50% ($200 maximum payable per calendar year)
Out-of-Network Provider: Not covered
Prosthetics and corrective appliances:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Outpatient prescription drugs:Filled at participating pharmacy (up to a 30-day supply); not covered at non-participating pharmacies, Filled through mail order (up to a 90-day supply), Twice the Level copayment.
In-Network Provider: 30% after plan deductible
Out-of-Network Provider: Not covered
Other Health Net of California health insurance plans:
