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GroupHealth Cooperative - HealthPaysTM Benefits
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Benefit Schedules:
Balance 1000 | Balance 1500 | Balance 2500 | Balance 5000 | HealthPays™ | Welcome
Plans
Rate Schedules:
Balance 1000 | Balance 1500 | Balance 2500 | Balance 5000 | HealthPays™ | Welcome
Plans
| HealthPays HSA Benefits |
| |
Alliant Plus
In-network |
Alliant Plus
Out-of-network |
| Annual Deductible |
$2,000 per Individual or $5,000 Family |
| Member Coinsurance |
90% |
80% |
| Out-of-Pocket Limit+ |
$5,100 per member or
$10,200 per family |
| Lifetime Maximum Benefits
|
$2,000,000 |
$2,000,000 |
| Benefits |
After deductible, member pays |
| Office visits |
10% |
20% |
| Manipulative therapy |
10%, up to 10 visits PCY † |
20%, up to 10 visits PCY |
| Acupuncture |
10%, up to 8 visits PCY |
20% |
| Naturopathy |
10%, up to 3 visits PCY |
20% |
| Maternity care |
Not covered |
Not covered |
Mental health services
Inpatient services: Limit total visits PCY to 12 combined for both in- and out-of-network. |
10% |
20% |
Mental health services
Outpatient services: Limit total visits PCY to 12 combined for both in- and out-of-network. |
10% |
20% |
| Lab/X-ray Services |
10% |
20% |
Hospital Visits - Inpatient
Hospital room and board; inpatient surgery;
anesthesia, intensive and coronary care;
laboratory tests; radiology services; drugs
while in hospital. Maternity care not covered. |
10% |
20% |
| Prescription drugs |
Not covered |
Not covered |
| Emergency care |
10% |
20% |
| Vision Care |
Not covered |
Not covered |
| |
Deductible does not apply |
Preventive care visits
For children and adults, including physicals and immunizations, as established
in GroupHealth’s preventive care schedule. |
10% |
20%
$300 individual/$600 family
annual benefit maximum |
+ Member coinsurance and annual deductible apply to out-of-pocket limit.
† PCY = per calendar year
‡ Western Washington counties: King, Kitsap, Pierce, Snohomish, Island, Thurston, Whatcom, Skagit, San Juan, Mason,
Lewis, and Gray’s Harbor (ZIP codes: 98541, 98557, 98554, & 98568). Central/Eastern Washington counties: Kittitas,
Yakima, Benton, Franklin, Walla Walla, Columbia, Whitman, and Spokane.
* When three or more children are covered, the first two up to age 25 are billed.
Note: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions
of the master policy or agreements. Other terms and conditions apply. Lifetime benefit maximum of $2 million applies to
all plans. All plans cover on-the-job-injury-related health care costs for partners, proprietors, or corporate officers who are
not covered by a workers’ compensation act, subject to the plan’s cost shares and benefit limitations.
Coverage provided by Group Health Options, Inc.
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Asuris
NW Health