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UnitedHealthcare - Qualified High Deductible Health Plan (QHDHP) with HSA
Benefit Plan
In-Network
Out-of-Network
Deductible
(embedded)
$2,600 / Single
$5,200/ Family
$5,000 / Single
$10,000 / Family
Coinsurance
0%
30%
Out-of-Pocket Maximum (includes deductible and
coinsurance
$2,600 / Single
$5,200 / Family
$8,000 / Single
$16,000 / Family
Physician Office Visit
Deductible Applies
Deductible, then you pay 30%
Preventive Care (includes office visit & certain tests
100% Covered
Deductible, then you pay 30%
Inpatient Hospital & Outpatient Surgery
Deductible Applies
Deductible, then you pay 30%
Diagnostic Lab, X-Ray and Other Tests
Deductible Applies
Deductible, then you pay 30%
Emergency Room
Deductible Applies
Same as In Network
Urgent Care Center
Deductible Applies
Deductible, then you pay 30%
Prescription Drug Coverage
Retail Pharmacy Copay
Deductible Applies
Deductible, then you pay 30%
Mail Order Pharmacy
Deductible Applies
Deductible, then you pay 30%
Type of Coverage
Monthly
Cost 2016
Employee Only
$0
Employee & Spouse
$130
Employee & Spouse + 1
$250
Employee & Spouse + 2
$370
Employee & Children (1)
$70
EMPLOYEE COST
Employee & Children (2)
$150
Monthly
Cost 2017
$0
$130
$250
$370
$70
$150
■
If you elect the QHDHP, you may also participate in a
Health Savings Account (HSA). Details of the HSA
are on the following pages. The District contributes
a
one time lump sum payment of $520 into the HSA
with the first payroll in January and $40 per
payroll thereafter for an annual total of $1,440!
■
With an embedded deductible, the health plan begins
to make payments as soon as one member of the
family has reached the individual deductible limit. For
example, if an individual in your family reaches the
$2,600 deductible limit all of his/her in network claims
for the remainder of the calendar year will be covered
even though the family deductible of $5,200 has not
been met.
■
Prescription Drug Benefit through Express Scripts .
■
The employee cost is covered by District.
■
Dependents are covered until 26 (end of month).
PLAN HIGHLIGHTS