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Medical Insurance: Medical Insurance Options Sample Grid

The following grid is a sample of what you may receive from your employer when you are first hired, or during Open Enrollment.

You may receive booklets regarding your choices.

These booklets may contain additional information about what specifically is covered by each plan, as well as exclusions (what is not covered by each plan).

There may be additional information regarding coverage for vision care, dental care, life insurance, and/or a 401K plan.

There should be phone numbers provided for you to ask questions.

The information contained in this grid is for the purpose of illustration only. It is not intended to influence your future decisions about what type of insurance coverage you should choose.

Plan Name HMO PPO HSA - PPO
Plan Description Lowest price - you must use participating providers. You will be assigned a PCP(primary Care Physician). All services, other than true emergency care must be pre-authorized. You have the flexibility of choosing your provider. Your out-of-pocket costs will be reduced by choosing participating providers. You must meet the deductible prior to your insurance contributing. Same coverage as the PPO. In addition, an HSA account will be established for you. The employer will initiate the account will an allocation of $500.00. This account may be used to offset your out-of-pocket expenses.
Monthly Premium Employee - $125.00
Emp+One - $175.00
Family - $215.00
Employee - $150.00
Emp+One - $225.00
Family - $275.00
Employee - $160.00
Family - $300.00
Annual Deductible n/a Employee - $500.00
Emp+One - $750.00
Family - $1,100.00
Employee - $1,000.00
Family - $2,000.00
CoPay/Coinsurance $25.00 office visit
$20.00 lab
$500.00 hospital (non-emergency)
$250.00 hospital (emergency)
Once the deductible is satisfied:
20% for participating providers
40% for non-participating providers
Once the deductible is satisfied:
20% for participating providers
40% for non-participating providers
Annual Out-of-Pocket Max n/a Employee - $2,500.00
Emp+One - $4,000.00
Family - $6,000.00
Employee - $2,500.00
Family - $6,000.00
Emergency Care 100% covered for participating facilities only. Once the deductible is satisfied:
20% for true emergencies whether participating or non-participating.
Once the deductible is satisfied:
20% for true emergencies whether participating or non-participating.
Preventive Services 100% covered, no co-pay required, for preventives services outlined in plan summary. 100% covered, no out-of-pocket expense for preventive services outlined in plan summary. 100% covered, no out-of-pocket expense for preventive services outlined in plan summary.
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