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2016 Benefits Guide
6
Qualified High Deductible Plan with Health Savings Account
Benefit/Service
In Network
Non-Network
Deductible
$3,000 / Individual
$6,000 / Family
$6,000/ Individual
$12,000 / Family
Coinsurance
100%
80%
Out-of-Pocket
Maximum
$3,000 / Individual
$6,000 / Family
$9,000 / Individual
$15,000 / Family
Office Visit
Deductible
80%
After Deductible
Preventive Care
100% Covered
80%
After Deductible
Inpatient/Outpatient
Hospital Services
100%
After Deductible
80%
After Deductible
Urgent Care
100%
After Deductible
80%
After Deductible
Emergency Room
100%
After Deductible
80%
After Deductible
Prescription
Co-Pay
Mail Order
Co-Pay
Tier 1 / Tier 2 / Tier 3
Deductible then $0
Deductible then $0
Not Covered
Not Covered
If you elect the QHDHP you may participate in the Health
Saving Account (HSA). If you cover your spouse and/or chil-
dren, the “family” deductible and out-of-pocket maximums
must be satisfied before benefits are paid. The District will
deposit $125 on a monthly basis into your HSA.
QUALIFIED HIGH DEDUCTIBLE PLAN WITH HSA
Type of Coverage
District
Paid
Premium
District
Dependent
Contribution
District Paid
HSA
Contribution
Employee
Contribution
Employee
$360.57
-
$125.00
$0.00
Employee & Spouse
$392.95
$120.00
$125.00
$219.04
Employee &
Child(ren)
$392.95
$110.00
$125.00
$92.01
Employee & Family
$392.95
$180.00
$125.00
$382.60
Allotment
Balance
$32.38
-
-
-
QHDHP Employee Monthly Contribution
If you elect to enroll in the Qualified High Deductible
Health Plan you are required to enroll in the Health
Savings Account. The District requires $125 per month
from the benefit allocation to be deposited in your HSA
account.
If you are enrolling in the Health Savings Account for the
first time, you must
complete the Anthem Benefit Wallet
HSA enrollment form and a Transfer of Funds form is
required for current H.S.A participants. These forms will
be found in the online enrollment process. Your account
cannot be set up until these forms are signed and
returned to Barb Daves in the Business Office.
IRS rules dictate calendar maximum deposits into Health
Savings Accounts. The maximum amount includes the
District’s contribution plus any additional deposits you
elect to add to your account. You cannot exceed these
set maximums.
Since the District contributes $1,500 a year into your
account, the employee maximum contribution levels for
2016 are $1,850 for Single and $5,250 for Family
coverage. You may not put more than this amount in the
account; you may put less. Individuals who are age 55
or older can also contribute an additional $1,000 in catch
up contributions per year.
Get the most out of your
insurance by using
in-network providers.