| Culpeper County Government 2024-2025 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 $2500.00 / $1000 $3.50/month from HSA Account |
| Deductible | $1500/$3000 | $2000 (Individual) / $4000 (Family) |
| OUTPATIENT OFFICE VISITS PCP Specialist |
AFTER PLAN YEAR DEDUCTIBLE $30 $60 | 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 $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 |
| 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 $30.00 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 | $4500/$9000 | $3500/$7000 |
| 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. | |