|
KPS health plans
Apply Online Now - Electronic Application
Index | Exclusions | Provider
Directory | Download Application
Benefit Schedules:
Sound Harbor Elite | Essential Plus | Essential Five | HSA
| HSA with RX
Rate Schedules:
Sound Harbor Elite | Essential Plus | Essential Five | HSA | HSA
with RX
SUMMARY OF BENEFITS
| |
The Healthy Investor TM Individual/Family HSA with Rx |
| Annual Deductible* - Individuals Only |
$1,750 or $2,600 |
| Annual Deductible* - Families
Only |
$3,500 or $5,150+ |
Annual Coinsurance Maximum
- Individual
(includes deductible) |
$5,000 |
Annual Coinsurance Maximum
- Family
(includes deductible) |
$10,000 |
| Lifetime maximum |
$1,000,000/person |
Preventive Care:
(Not subject to deductible, unless otherwise stated)
Annual Routine Physical Exam
Well-Baby Exam (to 24 months of age)
Annual Routine Eye Exam
Smoking Cessation- Professional Services |
Not a benefit if you choose a non–participating provider
80%
80% (exams only not subject to deductible)
80% (subject to deductible)
80% (subject to deductible)
$300 maximum per year total for all preventive care, except well baby care |
Professional Services
Office, home, naturopath or urgent care visits
Other outpatient professional services |
80%
80% |
Outpatient Lab & X-Ray
Mammography Services and Prostate Cancer Screening-Routine
Mammography Services and Prostate Cancer Screening-Diagnostic |
80%
80% (not subject to deductible)
80% (subject to deductible)
|
Facility/Hospital
Inpatient
|
80% |
Facility/Hospital
Outpatient |
80% |
| Emergency Room & Supplies |
80% |
Acupuncture
(12 treatments per year maximum) |
80% |
Ambulance Services
Air and Ground Combined - $5,000 max per year |
80% |
Home Health and Hospice
Home Health – 60 visits maximum
Hospice – 6 months maximum per year |
80%
80% |
| Maternity |
Not a benefit |
Medical Equipment & Supplies
$2,500 per calendar year maximum |
80% |
Mental Health
Inpatient (prior authorization required)-10 days per year maximum
Outpatient-12 visits per year maximum |
80%
80% |
Nutritional Guidance
$400 maximum per year |
80% |
Outpatient
Rehabilitation
(Physical, Speech, Massage & Occupational Therapy) |
80%
($500 maximum per year) |
| Prescriptions |
80% (subject to deductible) |
Skilled Nursing Facility
(in lieu of hospitalization) |
80% |
Spinal & Extremity Manipulations
(12 manipulations per year maximum)
|
80% |
| Sterilization |
Not a benefit |
| Vision Hardware |
Not a benefit |
All benefits are subject to annual deductible unless otherwise stated. This
benefit comparison contains only a brief explanation of the more important coverage
features offered. It does not constitute a contract. Complete coverage details,
including waiting periods and other limits and exclusions, are in the Benefits
Booklet. In the event of discrepancies, the Benefits Booklet shall govern.
*After member satisfies the annual deductible and coinsurance maximum, KPS
pays 100% of covered benefits for the remainder of the calendar year. If you
choose a Non-Participating Provider, your coinsurance costs are higher. In addition,
it is your responsibility to pay the difference between any amounts billed by
the Non-Participating Provider or Facility and the amount paid by KPS.
+The Healthy Investor TM family plans are designed for two or more family members. The entire family deductible must be satisfied before benefits are paid, annual routine physical exams, well-baby exams and routine mammography are not subject to the annual deductible.
Note: This summary contains a brief explanation of the
coverage features offered through KPS Health Plans. It does not constitute a
contract. Complete coverage details are in the Benefit Booklet. In the event
of discrepancies, the Benefit Booklet shall govern. There are exceptions, limitations,
and reductions which may affect your coverage.
|
Asuris
NW Health