Silver Compass HSA 3000
Silver Compass HSA 3000
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Important Questions |
Answers |
Why This Matters: |
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What is the overall deductible? |
Network: $3,000 individual / $6,000 family Per calendar year. Does not apply to services listed below with copays or "No Charge." |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. |
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Are there other deductibles for specific services? |
No. |
You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. |
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Is there an out-of-pocket limit on my expenses? |
Yes. Network: $6,500 individual / $13,000 family |
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. |
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What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges and health care this plan doesn’t cover |
Even though you pay these expenses, they don’t count toward the out-ofpocket limit. |
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Is there an overall annual limit on what the plan pays? |
No. |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
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Does this plan use a network of providers? |
Yes. For a list of network providers, see uhc.com/find–a–physician/xilcompass or call 1-877-512-9940. |
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. |
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Do I need a referral to see a specialist? |
Yes. An electronic referral is required to see a Network Specialist |
This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist. |
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Are there services this plan doesn’t cover? |
Yes. |
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. |
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Common |
Services You May Need |
Your Cost If |
Your Cost If |
Your Cost If |
Limitations & Exceptions |
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If you visit a health care provider’s office |
Primary care visit to treat an injury or illness |
0% co-ins after deductible |
Not Covered |
Not Covered |
Primary care provider (PCP) must be assigned. No referral required for |
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Specialist visit |
0% co-ins after deductible |
Not Covered |
Not Covered |
Referrals must be from assigned PCP. |
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Other practitioner office visit |
0% co-ins after deductible |
Not Covered |
Not Covered |
Limited to 16 visits of manipulative (chiropractic) services per year. |
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Preventive care / screening / immunization |
No Charge |
Not Covered |
Not Covered |
Includes preventive health services. |
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If you have a test |
Diagnostic test (x-ray, blood work) |
Freestanding: |
Freestanding: |
Not Covered |
Hospital: 30% co-ins after deductible |
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Imaging (CT / PET scans, MRIs) |
Freestanding: |
Freestanding: |
Not Covered |
Hospital: 30% co-ins after deductible |
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If you need drugs to |
Tier 1 – Your Lowest-Cost |
Retail: $5 copay |
Retail: $5 copay |
Not Covered |
Provider means pharmacy for |
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treat your illness or
More information about prescription drug coverage is available at |
Option |
after deductible |
after deductible |
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purposes of this section. Retail: Up to a 31 day supply. |
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Tier 2 – Your Midrange-Cost Option |
Retail: $40 copay after deductible |
Retail: $40 copay after deductible |
Not Covered |
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Tier 3 – Your Highest-Cost Option |
Retail: 20% coins after |
Retail: 20% coins after |
Not Covered |
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Tier 4 – Additional High-Cost Options |
Retail: 30% coins after |
Retail: 30% coins after |
Not Covered |
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If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
Freestanding: |
Not Covered |
Not Covered |
Hospital: 30% co-ins after deductible |
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Physician / surgeon fees |
0% co-ins after deductible |
Not Covered |
Not Covered |
–––––––––––none––––––––––– |
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If you need immediate medical attention |
Emergency room services |
0% co-ins after deductible |
0% co-ins after deductible |
0% co-ins after deductible |
–––––––––––none––––––––––– |
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Emergency medical transportation |
0% co-ins after deductible |
0% co-ins after deductible |
0% co-ins after deductible |
–––––––––––none––––––––––– |
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Urgent care |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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If you have a hospital stay |
Facility fee (e.g., hospital room) |
0% co-ins after deductible |
Not Covered |
Not Covered |
–––––––––––none––––––––––– |
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Physician / surgeon fees |
0% co-ins after deductible |
Not Covered |
Not Covered |
–––––––––––none––––––––––– |
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If you have mental health, behavioral health, or substance abuse needs |
Mental / Behavioral health outpatient services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible |
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Mental / Behavioral health inpatient services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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Substance use disorder outpatient services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible |
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Substance use disorder inpatient services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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If you are pregnant |
Prenatal and postnatal care |
No Charge |
No Charge |
Not Covered |
Additional copays, deductibles, or coinsurance may apply. |
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Delivery and all inpatient services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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If you need help recovering or have other special health |
Home health care |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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Rehabilitation services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
Limits per calendar year: physical, speech, occupational – unlimited visits; cardiac – 72 visits; pulmonary – 20 visits. |
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Habilitative services |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
Limits are combined with |
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Skilled nursing care |
0% co-ins after |
0% co-ins after |
Not Covered |
–––––––––––none––––––––––– |
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deductible |
deductible |
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Durable medical equipment |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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Hospice service |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
–––––––––––none––––––––––– |
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If your child needs |
Eye exam |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
1 exam every 12 months. |
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Glasses |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
1 pair every 12 months. Cost may increase depending on the frames. |
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Dental check-up |
0% co-ins after deductible |
0% co-ins after deductible |
Not Covered |
Cleanings covered 2 times per 12 months. Limitations may apply. |
Excluded Services & Other Covered Services:
| Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
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| Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
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