Health Benefits
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Culpeper County Government 2022-2023 Benefit Plan Options |
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HealthKeepers 25/1000
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Lumenos HSA 4
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| Type of Spending Account Account Manager Amount Deposited Mid-October Service Charge |
Flexible Spending Account
Flexible Benefits Administrators
$250.00 |
Health Savings Account
Union First Market Bank $2500.00 / $1000 $3.50/month from HSA Account |
| Deductible |
$1500/$3000
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$2000 (Individual) / $4000 (Family)
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| OUTPATIENT OFFICE VISITS PCP Specialist |
AFTER PLAN YEAR DEDUCTIBLE
$30
$60
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10% after plan year deductible
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| Preventative Care | ||
| Check-ups, GYN exam and pap test |
100 % AC
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100 % AC
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| Prostate Exam and PSA |
100 % AC
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100 % AC
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| Mammogrpahy screenings |
100 % AC
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100 % AC
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| Screenings/Immunizations |
100 % AC
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100 % AC
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| Colorectal cancer screenings |
100 % AC
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100 % AC
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| Well Baby Care | ||
| Check-ups, Visits |
100 % AC
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100 % AC
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| Screening tests |
100 % AC
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100 % AC
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| Immunizations |
100 % AC
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100 % AC
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Annual Vision Exam |
$15.00 co-pay
$30.00 OON allowance |
$15.00 co-pay
$30.00 OON allowance |
| Diagnostic Tests1 Advanced Diagnostic Imaging |
After Plan Year Deductible
$30.00 PCP/$60.00 Specialist After Plan Year Deductible $150.00 |
10% after Plan Year Deductible
10% after Plan Year Deductible |
| Physical Therapy/Occupational Therapy/Speech Therapy2 |
After Plan Year Deductible
$30.00 co-pay |
10% after Plan Year Deductible
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| Outpatient Surgery3 |
After Plan Year Deductible
$150.00 co-pay |
10% after Plan Year Deductible
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| Pre/Post Natal Care4 |
After Plan Year Deductible
$300.00 co-pay |
10% after Plan Year Deductible
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| Outpatient Mental Health/Substance Abuse Visits |
After Plan Year Deductible
$30.00 co-pay |
10% after Plan Year Deductible
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| Inpatient Hospital Services |
After Plan Year Deductible |
10% after Plan Year Deductible
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| Skilled Nursing5 |
After Plan Year Deductible
20% |
10% after Plan Year Deductible
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| Durable Medical Equipment |
After Plan Year Deductible
$0 |
10% after Plan Year Deductible
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| Ambulance Services |
After Plan Year Deductible
$100 per transport |
10% after Plan Year Deductible
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| Emergency Room6 |
After Plan Year Deductible
$250 |
10% after Plan Year Deductible
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| Out-Of-Pocket7 |
$4500/$9000
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$3500/$7000
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| Prescription Drug Retail Mail Order |
$15/$35/$55 or 20%
$30/$70/$110 or 20% |
10% after Plan Year Deductible
10% after Plan Year Deductible |
| 1 If rendered with an office visit the member will only be responsible for an office visit co-payment 2 30 combined PT/OT visits and 30 ST visits (per member plan per year) 3 Free standing ambulatory surgery center or hospital based facility 4 All routine outpatient per- and postnatal care of the mother rendered by the OB/GYN 5 100 days per admission 6 Covered only for true emergency services; co-pay waived if admitted 7 Individual/Family; Does not include co-payments/coinsurance/deductibles for vision benefits or dental rider benefits |
**If you also cover Dependents (other family members) under the LUMENOS HSA 4 Plan, only the “per Family” amounts apply, and the “per Member” amount will not apply. The “per Family” amount may be met in its entirety by one family member, or by a combination of family members. | |
