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Culpeper County Government 2019-2020 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
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Health Savings Account
Union First Market Bank
$2000.00 / $500
$3.50/month from HSA Account
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| Deductible |
$1000/$2000
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$1500 (Individual) / $3000 (Family)
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OUTPATIENT OFFICE VISITS
PCP
Specialist |
AFTER PLAN YEAR DEDUCTIBLE
$25
$50
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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
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$15.00 co-pay
$30.00 OON allowance
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$15.00 co-pay
$30.00 OON allowance
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Diagnostic Tests1
Advanced Diagnostic Imaging |
After Plan Year Deductible
$25.00 PCP/$50.00 Specialist
After Plan Year Deductible $150.00
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10% after Plan Year Deductible
10% after Plan Year Deductible
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| Physical Therapy/Occupational Therapy/Speech Therapy2 |
After Plan Year Deductible
$25.00 co-pay
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10% after Plan Year Deductible
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| Outpatient Surgery3 |
After Plan Year Deductible
$150.00 co-pay
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10% after Plan Year Deductible
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| Pre/Post Natal Care4 |
After Plan Year Deductible
$300.00 co-pay
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10% after Plan Year Deductible
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| Outpatient Mental Health/Substance Abuse Visits |
After Plan Year Deductible
$25.00 co-pay
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10% after Plan Year Deductible
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| Inpatient Hospital Services |
After Plan Year Deductible
$300.00 day/not to exceed $1500.00 per admission
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10% after Plan Year Deductible
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| Skilled Nursing5 |
After Plan Year Deductible
20%
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10% after Plan Year Deductible
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| Durable Medical Equipment |
After Plan Year Deductible
$0
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10% after Plan Year Deductible
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| Ambulance Services |
After Plan Year Deductible
$100 per transport
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10% after Plan Year Deductible
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| Emergency Room6 |
After Plan Year Deductible
$250
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10% after Plan Year Deductible
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| Out-Of-Pocket7 |
$4000/$8000
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$3000/$5950
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Prescription Drug
Retail
Mail Order |
$10/$30/$50 or 20%
$20/$60/$100 or 20%
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10% after Plan Year Deductible
10% after Plan Year Deductible
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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 |