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(Available to Washington State Residents Only)
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SUMMARY OF BENEFITS
INDIVIDUAL REGENCE HSA HEALTHPLAN
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For medically necessary services rendered by a Preferred Plan, participating, or recognized provider, the benefits of this plan will be provided at the percentage of the allowed amount as specified below after the deductible has been met. Unless otherwise specified, all benefits are subject to the annual deductible in addition to any coinsurance. When you, or you and your family, have reached the annual out-of-pocket maximum, this plan will provide benefits at 100% of the allowed amount for the remainder of the calendar year for the services of Preferred Plan providers only, unless otherwise specified. Any balances of charges not covered by this plan will be your, or you and your family's, responsibility to pay. Services provided by participating providers do not apply toward the annual out-of-pocket maximum.
Deductible, coinsurance and copay represent WHAT YOU PAY.
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Benefits |
Preferred Plan
Provider |
Participating
Provider |
Annual Deductible
Family deductible applies when the subscriber and one or more dependents are enrolled. Proior to benefits being paid for any family
member, the entire family deductible must be met.
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$2,500 or $3,500 member
$5,000 or $7,000 family |
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Lifetime maximum: |
$2,000,000 per member |
Annual Out-of-Pocket Amount
The total amount of coinsurance and deductible amount you, or you and your family, are responsible to pay during a calendar year for covered services, after which the plan will provide 100% of the allowed amount for the remainder of that calendar year, unless otherwise specified. Any balances of charges not covered by this plan will be your, or you and your family's, responsibliity to pay. The family out-of-pocket amount applies when the subscriber and one or more dependents are enrolled. Proir to benefits being paid for any family member at 100% the entire family out-of-pocket maximum must be met.
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$5,000 member
$10,000 family |
No out-of-pocket maximum |
Professional Services
Including diagnostic x-ray and laboratory. Coverage includes the services of physicians, osteopaths, naturopaths, and other eligible health care professional providers
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| 20% |
40% |
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Hospital Facility
(Inpatient & Outpatient)
Including diagnostic x-ray and laboratory
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20% |
40% |
Acupuncture
12 visits per calendar year maximum
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20% |
40% |
Ambulance Services**
Ground services: $2,000 per calendar year maximum
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20% |
20% |
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Blood Bank**
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20% |
20% |
Home Health and Hospice
Home Health - 130 visits per calendar year maximum
Hospice - 6 months maximum
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20% |
20% |
Home Medical Equipment
$2,500 per calendar year maximum
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20% |
40% |
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Home Phototherapy
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20% |
20% |
Infusion Therapy
Growth hormone treatment is limited to $20,000 per calendar year
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20% |
40% |
Mammography
Routine mammograms not subject to deductible
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20% |
40% |
Mental Disorders
Inpatient - 8 days per calendar year
Outpatient - 12 visits per calendar year
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20% |
40% |
Occupational Injury
(provided for the subscriber only)
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20% |
40% |
Phenylketonuria (PKU) Formulas
Not subject to waiting periods
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20% |
20% |
Preventive Care
(not subject to deductible)
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20% |
40% |
Prostate Cancer Screening
Routine prostate cancer screenings not subject to deductible
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20% |
40% |
Prosthetics and Orthotics
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20% |
40% |
Rehabilition
Inpatient - $4,000 per calendar year maximum
Outpatient - $2,000 per calendar year maximum
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20% |
40% |
Skilled Nursing Facility
30 days per calendar year maximum
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* |
20% |
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Special Equipment and Supplies
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20% |
20% |
Spinal Manipulations
10 manipulations per calendar year maximum
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20% |
40% |
Transplants
$250,000 lifetime maximum;
12 month waiting period
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20% |
40% |
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*At this time, this service is provided only by participating providers.
**At this time, these services are provided only by recognized providers.
Cost Containment Provisions: All hospital and skilled nursing facility admissions must be medically necessary.
Preadmission approval is required for all inpatient admissions outside the service area if you seek care from providers who have not contracted with a Blue Cross and/or Blue Shield plan, except for emergency services.
Emergency Care: Emergency benefits will be provided at the level specified for a Preferred Plan provider. In the event of a medical emergency, treatment by a provider not normally covered under this plan will be recognized for a 24-hour period or for such additional time as is reasonably required to come under the care of a Preferred Plan provider. Benefits will be based on the recognized provider's actual charge for the service.
Care Outside the Service Area: All care received outside the service area will be paid the same as in the service area if you use a Preferred Plan or participating provider. Payment will be based on the allowed amount. To receive the highest benefit level, you must receive services from a Preferred Plan provider. If there is no Preferred Plan provider network in an area, benefits will be provided for care received from a participating provider at the level specified for Preferred Plan providers. Benefits will be provided for care received from a recognized provider at the level specified for Preferred Plan providers only if there is no local Blue Cross and/or Blue Shield participating provider network in a particular area and for medical emergencies. Call 1-800-810-BLUE(2583) for names of Preferred Plan or participating providers with the local Blue Cross and/or Blue Shield plan. When you need health care outside of the United States or its territories, call the BlueCard Worldwide Service Center at 1-800-810-BLUE or call collect at 1-804-673-1177. If you are admitted to a hospital while traveling outside the service area, you must contact the Company within 24 hours to receive full plan benefits. If you meet all requirements, inpatient benefits will be provided at the level specified for Preferred Plan providers for like services and supplies.
Waiting Periods: No benefits are provided for treatment relating to a transplant until you have been covered under this or a prior plan with the Company (Regence BlueShield) for 12 consecutive months. No benefits will be provided for preexisting conditions until you have been covered under this plan for nine consecutive months, unless you were continuously covered for at least nine months under the immediately preceding creditable plan.
This is a brief summary of benefits; it is not a certificate of coverage. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, refer to the plan contract.
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E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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