HSA's Qualified Plan for Individuals- in Nevada (Summary of Benefits at a Glance
This summary provides you with the deductible, coinsurance, and a brief description of your benefits.
| Plan Types:
Offered in
Nevada 1500D/1500-100% 2000D/2000-100% 3000D/3000-100% 4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70%
|
Preferred Providers
Individuals: (Deductible) $1,500 $2,000 $3,000 $4,000 $5,000 $1,500 $2,000 $3,000
|
Preferred Providers
Family: (Deductible) $3,000 $4,000 $6,000 $8,000 $10,000 $3,000 $4,000 $6,000
|
Non-Preferred Providers
Individuals: (Deductible) $3,000 $4,000 $6,000 $8,000 $10,000 $3,000 $4,000 $6,000
|
Non-Preferred Providers
Family: (Deductible) $6,000 $8,000 $12,000 $16,000 $20,000 $6,000 $8,000 $12,000
|
| Services | What you pay after your deductible for Preferred Providers | What you pay after your deductible for Non-Preferred Providers | Additional Information |
| Ambulance Service 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70%
|
Plan pays100%coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance
|
Plan pays100%coinsurance Plan pays100%coinsurance Plan pays100%coinsurance Plan pays100%coinsurance Plan pays100%coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance | Benefits are paid for medically necessary ground or
air ambulance transportation. Ground Services are limited to a maximum
benefit of $700 per trip. Air Service are limited to a maximum benefit
of $5,000 per trip.
Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Alcohol & Drug Abuse 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70%
|
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance | Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance | Benefits are paid for medically necessary treatment
for detoxification up to $1,500; inpatient or outpatient rehabilitation
$9,000: and counseling $2,500 per calendar year. Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Chemotherapy, Hemodialysis, and
Radiation Therapy 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 00% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Diagnostic Service, Laboratory,
Pathology, and X-rays 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance
is the percentage Anthem will pay toward your approved Medical costs,
after your deductible. Services billed by a hospital are included in the hospital inpatient/outpatient benefits. |
| Emergency Care 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Home Health Care 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance
is the percentage Anthem will pay toward your approved Medical costs,
after your deductible. Benefits are limited to 60 visits per calendar year. |
| Hospice Care 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance
is the percentage Anthem will pay toward your approved Medical costs,
after your deductible. Benefit period of three months, up to maximum of two additional benefit periods, subject to a $5,000 payment limit per benefit period, payable at $55 per day. |
| Hospital Care 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
All Plans Inpatient/Outpatient Surgery & Outpatient
Nonemergency Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Maternity Care 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Inpatient/Outpatient Benefits are paid for
complications of pregnancy only. Routine maternity care is not covered. Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Severe Mental Illness 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance
is the percentage Anthem will pay toward your approved Medical costs,
after your deductible. Benefits are paid up to 40 inpatient days, 80 partial days (combined). Outpatient services are paid up to 40 visits per calendar year. |
| Physical Rehabilitation (physical, occupational, and speech therapy)1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance
is the percentage Anthem will pay toward your approved Medical costs,
after your deductible.
Inpatient benefits are paid up to 45 days per year. Outpatient benefits are paid up to 12 visits for physical therapy, 12 visits for occupational therapy and 12 visits for speech therapy per calendar year. |
| Physician Visits 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Preventive Care
Children 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
(Not subject to deductible) Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Routine child exam through age 12 Immunizations through age 12 Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Preventive Care
Adults 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70%
|
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance | Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance | Routine exams and immunizations, routine pap smear,
routine mammography. routine prostate screening.
Except for routine mammography and prostate screening which are not subject to deductible and coinsurance. Maximum annual benefit of $500, this maximum payment is combined from in-Network and Out-of-network providers. Mammogram screening and prostate screening are not subject to the maximum payment, but do reduce the maximum payment of $500. Annual pap smears for women 18 years or older. One screening mammogram for women between 35 and 40; and annual mammogram for women over 40 years of age. One yearly prostate screening for men 50 years of age and older, and in high-risk men 40 years of age and older. |
| Spinal Manipulations and Acupuncture 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Benefits are limited to a maximum of 12 visits per
calendar year per member combined with acupuncture cares. Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Supplies Equipment, and Appliances (DME)1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% |
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Note: Coinsurance is the percentage Anthem will pay toward your approved Medical costs, after your deductible. |
| Temporal Mandibular Joint Syndrome (TMJ)1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70% | Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
Benefits are paid up to a $4,000 lifetime maximum |
| Outpatient Prescription Drugs 1500D/1500-100% 2000D/2000-100%3000D/3000-100%4000D/4000-100% 5000D/5000-100% 1500D/5000-70% 2000D/5000-70% 3000D/5000-70%
|
Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays100% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance |
Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 70% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance Plan pays 50% coinsurance |
For more complete information, see the Prescription Drug Amendment to your certificate. The member can fill prescriptions through a participating pharmacy or non-participating pharmacy. Prescriptions can also be ordered though the participating mail order service. |
| Dental Injury | For treatment by a physician or dentist of an accidental injury to the natural teeth, if the injury occurs while you are covered under the agreement, and the services are received within 6 months of injury. |
| Dependent Eligibility | The end of the month in which the employee's unmarried dependent child becomes age 19, or 24 if financially dependent upon the subscriber. |
| Precertification | Inpatient Services Hospital (medical and surgical care) and Hospice care services are subject to precertification | Outpatient Service Outpatient surgeries in a Hospital are subject to precertification. |
| Maximum Out-of-Pocket Expense Amounts:
The maximum amount you will have to pay for
covered expenses under each plan Preferred Providers: Non-Preferred Providers: Plan Types: Individual Family Individual Family 1500D/1500-100% $1,500 $3,000 $4,000 $8,000 2000D/2000-100% $2,000 $4,000 $6,000 $12,000 3000D/3000-100% $3,000 $6,000 $10,000 $20,000 4000D/4000-100% $4,000 $8,000 $12,000 $24,000 5000D/5000-100% $5,000 $10,000 $15,000 $30,000 1500D/5000-70% $5,000 $10,000 $10,000 $20,000 2000D/5000-70% $5,000 $10,000 $10,000 $20,000 3000D/5000-70% $5,000 $10,000 $10,000 $20,000 Includes deductible and coinsurance Includes deductible and coinsurance *********LIFETIME MAXIMUM BENEFITS: $2,000,000 per member********* |
Reimbursement for covered services is based upon Allowable Charge as determined by Anthem. Charge means the Contracted Amount for Preferred Providers or the Maximum Benefit Allowance for Non-Preferred Providers. Our determination of Allowable Charge is the maximum amount we approve for any particular service. Deductible, coinsurance, or other cost sharing amount are based on this allowable and are the amounts you pay the provider.
Emergency- means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in: Serious jeopardy to the health of an insured ; or, serious jeopardy to the health of an unborn child; or, serious impairment to bodily functions; or, serious and permanent dysfunction of any bodily organ or part.
Medically Necessary- benefits are payable only for covered services and supplies that are medically necessary which meet the following definition.
1. Appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition, and Provided for the diagnosis or direct care and treatment of the medical condition. Within standards of good medical practice within the organized medical community, and not primarily for the convenience of the member, the member's physician or another provider.
2. The most appropriate supply or level of services which can safely be provided. For hospital stays this means acute care as an inpatient as necessary due to the kind of services you are receiving or the severity of you condition, and that safe and adequate care cannot be received as an outpatient or in a less acute medical setting. Claims for services that are not medically necessary may be denied either before or after payment of such services.
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Denise Brown Owner/Broker
Direct Health & Life of Nevada
Independent Authorized Nevada Agent
Phone: (702) 349-7579