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Oregon Medical Insurance > ODS Health Plans of Oregon > HSA Value Benefits


 
HSA PPO
Plan year deductible
(family deductible is 2x the individual)
$2,800 (individual)
$5,600 (family)
Out-of-Pocket Maximum, Per Member
(after deductible)
$2,200 (individual)
$4,400 (family)
No maximum
Plan Year Essential Benefit Maximum
$2,000,000
Preventive Care
Member Responsibility
The deductible is waived for in-network preventive care.
In Network Provider
Out of Network Provider
Annual women’s exam -Pap, pelvic, breast $0* 50%
Women's routine mammogram $0* 50%
Well-baby care $0* 50%
Routine Physical Exams $0* 50%
Immunizations $0* 50%
Professional Services
Office Visits
50%
50%
Alternative care ($1,000 per plan year limit)
Chiropractic, naturopathic and acupuncture
50%
50%
Facility and Ancillary Services
Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care
50%
50%
Maternity - All pre/post office visits and doctor delivery; hospital charges
50%
50%
Mental health - Inpatient, outpatient, residential
(see limitations and exclusions)
50%
50%
Alcohol / Mental Health Treatment
Inpatient, outpatient, residential combined
50%
50%
Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare
50%
50%
Vision
(see limitations and exclusions)		 Not covered
Emergency Services
Urgent care 50% 50%
Emergency room (deductible applies)
50%
Ambulance ($5,000 per plan year limit)
50%
Other Benefits
Prescription services
50%
Accident benefit
Paid as any other illness subject to deductible/coinsurance
*Deductible waived
Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.

 

 

 

 
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