HEALTH BENEFITS

 

 

Culpeper County Government 2019-2020 Benefit Plan Options

 

                   

 
HealthKeepers 25/1000
Lumenos HSA 4
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
$2000.00 / $500

$3.50/month from HSA Account
Deductible
$1000/$2000
$1500 (Individual) / $3000 (Family)
OUTPATIENT OFFICE VISITS
PCP
Specialist
AFTER PLAN YEAR DEDUCTIBLE
$25
$50
10% after plan year deductible
 
 
Preventative Care
Check-ups, GYN exam and pap test
100 % AC
100 % AC
Prostate Exam and PSA
100 % AC
100 % AC
Mammogrpahy screenings
100 % AC
100 % AC
Screenings/Immunizations
100 % AC
100 % AC
Colorectal cancer screenings
100 % AC
100 % AC
Well Baby Care
Check-ups, Visits
100 % AC
100 % AC
Screening tests
100 % AC
100 % AC
Immunizations
100 % AC
100 % AC

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
$25.00 PCP/$50.00 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
$25.00 co-pay
10% after Plan Year Deductible
Outpatient Surgery3
After Plan Year Deductible
$150.00 co-pay
10% after Plan Year Deductible
Pre/Post Natal Care4
After Plan Year Deductible
$300.00 co-pay
10% after Plan Year Deductible
Outpatient Mental Health/Substance Abuse Visits
After Plan Year Deductible
$25.00 co-pay
10% after Plan Year Deductible
Inpatient Hospital Services

After Plan Year Deductible
$300.00 day/not to exceed $1500.00 per admission

10% after Plan Year Deductible
Skilled Nursing5
After Plan Year Deductible
20%
10% after Plan Year Deductible
Durable Medical Equipment
After Plan Year Deductible
$0
10% after Plan Year Deductible
Ambulance Services
After Plan Year Deductible
$100 per transport
10% after Plan Year Deductible
Emergency Room6
After Plan Year Deductible
$250
10% after Plan Year Deductible
Out-Of-Pocket7
$4000/$8000
$3000/$5950
Prescription Drug
Retail
Mail Order

$10/$30/$50 or 20%
$20/$60/$100 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

Board of Supervisors Agendas and Minutes Adopted Budget Pay Taxes Request for Public Records (FOIA)

302 N. Main St, Culpeper, VA Phone: (540) 727-3427