Medical coverage and preventive care overview
Medical coverage and preventive care overview
Here’s a summary of your medical coverage under each of the MyChoice HSP options.
See the Medical Option Summaries on the on the enrollment website for details. In addition, the family deductible and out-of-pocket maximum work differently than those of MyChoice HSP 1 through Aetna, as detailed in the table below.
| MyChoice HSP 1 | MyChoice HSP 2 | MyChoice HSP 3 |
|---|---|---|
| Annual Deductible The MyChoice HSP options have a combined medical and prescription deductible, and separate deductibles for in-network and out-of-network services. For family coverage, the entire family deductible must be met before coinsurance applies for anyone in the family. |
||
| In-network | ||
Aetna: $1,500 individual / |
$2,100 individual / |
$3,375 individual / |
| Out-of-network1 | ||
$3,000 individual / |
$4,200 individual / |
$6,750 individual / |
| Coinsurance2 Once you meet your plan’s deductible, the plan begins to share the cost of your care. You pay a percentage of the cost of your care, and the plan pays the rest. | ||
| In-network | ||
Plan pays 80% / You pay 20% after the deductible | ||
| Out-of-network2 | ||
Plan pays 60% / You pay 40% after the deductible | ||
| Prescription Drugs (Value Formulary through CVS Caremark) | ||
| ||
| Mental Health Counseling | ||
| ||
| Annual Out-of-Pocket Maximum
For MyChoice HSP 1, for family coverage, the entire family out-of-pocket maximum must be met before the plan pays 100% of the cost of covered expenses for any family member for the rest of the plan year.4 For MyChoice HSP 2 and HSP 3, once one person in the family meets the individual out-of-pocket maximum (which is capped for in-network care at $6,750), all covered medical and prescriptions for that person will be covered at 100% for the rest of the plan year. Once the family out-of-pocket maximum is met,the plan pays 100% of the cost of covered expenses for all family members for the rest of the plan year. | ||
| In-network | ||
$3,000 per individual / $6,000 family maximum |
Individual coverage: $4,200 Family coverage:$6,750 per individual / |
Individual coverage: $6,750 Family coverage:$6,750 per individual / |
| Out-of-network | ||
$6,000 per individual / |
$8,400 per individual / |
$13,500 per individual / |
1 Out-of-network benefits are payable based on the recognized charge for each service. The recognized charge is based on a formula for determining typical charges for services in your area. Your costs above the recognized charge don’t count toward your deductible or out-of-pocket maximum.
2 Applies to non-preventive services, including office visits, lab tests, hospitalization, surgery and prescriptions. See the Medical Option Summaries on the enrollment website for details.
Keep in mind: Using Centers of Excellence (specialized surgical facilities that meet rigorous program requirements) for certain medical services, such as IVF, transplants and bariatric surgery, is required for all MyChoice HSP options. If you don’t use one of these facilities, your medical plan will not cover your treatment. You’ll pay the full cost out of your own pocket.
Your paycheck costs for coverage will depend on your annual benefits base rate (ABBR)*, the option you choose and who you cover.
You can see your personalized rates, ABBR** and summaries of the plans available to you on the enrollment website during the enrollment period.
* ABBR is not used for determining paycheck costs for HSP 1 Kaiser Permanente in California or HMSA in Hawaii. See below for information about these options.
Preventive care
All MyChoice HSP options provide the following coverage for in- and out-of-network care after you meet your plan’s deductible.
| In-Network | Out-of-Network | |
|---|---|---|
| Preventive Care | ||
Well child care (up to age 19) |
Covered at 100%; deductible does not apply |
You pay 40% |
Routine physicals (age 19 and older) |
Not Covered |
|
Immunizations, vaccinations |
Not Covered |
|
MinuteClinic visits |
Not Covered |
|
| Office Visits | ||
Illness or injury |
You pay 20% |
You pay 40%(Does not apply to MinuteClinic visits) |
Allergy shots |
||
Chiropractic care (15 visits per plan year) |
||
Physical, occupational and speech therapy |
||
Mental health and chemical dependency |
||
Inpatient and outpatient hospital services |
||
MinuteClinic visits (non-preventive) |
Covered at 100% after you meet your deductible |
Not applicable |
Lab and X-rays |
Preventive care is covered at 100% (deductible does not apply) |
Out-of-network preventive care is not covered |
| Emergency Care | ||
Hospital emergency room services |
You pay 20% |
After you meet your in-network deductible, you pay 20% |
Emergency ambulance |
||
| Other | ||
Durable medical equipment |
You pay 20% |
You pay 40% |
Home health care |
||
**Annual Base Benefits Rate (ABBR)
For the 2023−2024 plan year (June 1, 2023 − May 31, 2024), your ABBR is defined as follows:
If you have completed two or more years of service as of Feb. 28, 2023, ABBR is your annual salary, as of Feb. 28, 2023, plus your total averaged annual performance-related bonuses and commissions paid during the two-year period before Feb. 28, 2023.
If you have not completed two years of service as of Feb. 28, 2023, ABBR is your annual salary, as of Feb. 28, 2023, plus your total performance-related bonuses and commissions paid during the one-year period before Feb. 28, 2023.
If you were hired or were rehired after 13 weeks on or after Feb. 28, 2023, your ABBR is your annual salary as of your date of hire/rehire. If you terminate your employment and then are rehired within 13 weeks, your prior ABBR is restored.
ABBR is updated effective on June 1 each year if you are actively at work. If you are on paid or unpaid leave, your ABBR will not be updated until you return to work for one full day. Generally, your ABBR will not change throughout the plan year.
